51
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Fukuta H. Effects of Exercise Training on Cardiac Function in Heart Failure with Preserved Ejection Fraction. Card Fail Rev 2020; 6:e27. [PMID: 33133641 PMCID: PMC7592458 DOI: 10.15420/cfr.2020.17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/20/2020] [Indexed: 12/29/2022] Open
Abstract
Nearly half of patients with heart failure in the community have heart failure with preserved ejection fraction (HFpEF). Patients with HFpEF are often elderly and their primary chronic symptom is severe exercise intolerance. Left ventricular diastolic dysfunction is associated with the pathophysiology of HFpEF and is an important contributor to exercise intolerance in HFpEF patients. The effects of exercise training on left ventricular diastolic function in HFpEF patients have been examined in several randomised clinical trials. Meta-analysis of the trials indicates that exercise training can provide clinically relevant improvements in exercise capacity without significant change in left ventricular structure or function in HFpEF patients. Further studies are necessary to elucidate the exact mechanisms of exercise intolerance in HFpEF patients and to develop recommendations regarding the most effective type, intensity, frequency, and duration of training in this group.
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Affiliation(s)
- Hidekatsu Fukuta
- Core Laboratory, Nagoya City University Graduate School of Medical Sciences Nagoya, Japan
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52
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Lalande S, Cross TJ, Keller-Ross ML, Morris NR, Johnson BD, Taylor BJ. Exercise Intolerance in Heart Failure: Central Role for the Pulmonary System. Exerc Sport Sci Rev 2020; 48:11-19. [PMID: 31453845 DOI: 10.1249/jes.0000000000000208] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We propose that abnormalities of the pulmonary system contribute significantly to the exertional dyspnea and exercise intolerance observed in patients with chronic heart failure. Interventions designed to address the deleterious pulmonary manifestations of heart failure may, therefore, yield promising improvements in exercise tolerance in this population.
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Affiliation(s)
- Sophie Lalande
- Department of Kinesiology and Heath Education, The University of Texas at Austin, Austin, TX
| | | | - Manda L Keller-Ross
- Divisions of Physical Therapy and Rehabilitation Sciences, Department of Rehabilitation Medicine, Medical School, University of Minnesota, Minneapolis, MN
| | - Norman R Morris
- School of Physiotherapy and Exercise Science, Griffith University, Queensland, Australia
| | - Bruce D Johnson
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Bryan J Taylor
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, UK
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53
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Pugliese NR, Fabiani I, Santini C, Rovai I, Pedrinelli R, Natali A, Dini FL. Value of combined cardiopulmonary and echocardiography stress test to characterize the haemodynamic and metabolic responses of patients with heart failure and mid-range ejection fraction. Eur Heart J Cardiovasc Imaging 2020; 20:828-836. [PMID: 30753369 DOI: 10.1093/ehjci/jez014] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/11/2019] [Accepted: 01/21/2019] [Indexed: 12/19/2022] Open
Abstract
AIMS To characterize heart failure (HF) with mid-range ejection fraction (HFmrEF), combining cardiopulmonary exercise test, and exercise stress echocardiography. METHODS AND RESULTS We studied 169 consecutive subjects (age 62.3 ± 11 years; 74% male): 30 healthy controls, 45 patients with HF and preserved EF (HFpEF), 40 HFmrEF, and 54 with HF and reduced EF (HFrEF). Left ventricular (LV) stroke volume (SV), EF, elastance, global longitudinal strain, E/E', oxygen consumption (VO2), and arterial-venous oxygen content difference (AVO2diff) were measured in all exercise stages. HFmrEF revealed baseline features intermediate between HFrEF and HFpEF, except for B-type natriuretic peptide levels, which was similar to HFpEF and significantly lower than HFrEF. Peak VO2 was not significantly different between HF groups. HFrEF exhibited a significantly lower peak SV as compared to either HFpEF or HFmrEF (74.3 ± 21.8 mL vs. 88.0 ± 17.4 mL and 96.5 ± 25.1 mL; P < 0.01), whereas peak heart rate was not significantly different between HF groups. A significantly reduced AVO2diff at peak exercise was apparent in HFpEF and HFmrEF (15.2 ± 3.3 mL/dL and 13.3 ± 4.2 mL/dL) vs. HFrEF (17.±6.6 mL/dL; P < 0.01), whereas no significant difference was reported between HFpEF and HFmrEF. Multivariate analysis in the overall population and all groups revealed peak parameters as independent predictors of peak VO2 (R2 = 0.90, P < 0.0001); AVO2diff showed the largest standardized regression coefficient. CONCLUSION In HFpEF and HFmrEF, effort intolerance is predominantly due to peripheral factors (AVO2diff), whereas in HFrEF peak VO2 is restricted by low increases in SV. Individual therapy according to which component of VO2 is more impaired is advisable.
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Affiliation(s)
- Nicola Riccardo Pugliese
- Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Via Paradisa, 2, Pisa, Italy.,Cardiac, Thoracic and Vascular Department, University of Pisa, Via Paradisa, 2, Pisa, Italy
| | - Iacopo Fabiani
- Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Via Paradisa, 2, Pisa, Italy.,Cardiac, Thoracic and Vascular Department, University of Pisa, Via Paradisa, 2, Pisa, Italy
| | - Claudia Santini
- Cardiac, Thoracic and Vascular Department, University of Pisa, Via Paradisa, 2, Pisa, Italy
| | - Ilaria Rovai
- Cardiac, Thoracic and Vascular Department, University of Pisa, Via Paradisa, 2, Pisa, Italy
| | - Roberto Pedrinelli
- Cardiac, Thoracic and Vascular Department, University of Pisa, Via Paradisa, 2, Pisa, Italy
| | - Andrea Natali
- Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa, 2, Pisa, Italy
| | - Frank L Dini
- Cardiac, Thoracic and Vascular Department, University of Pisa, Via Paradisa, 2, Pisa, Italy
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54
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Heizer J, Carbone S, Billingsley HE, VAN Tassell BW, Arena R, Abbate A, Canada JM. Left ventricular concentric remodeling and impaired cardiorespiratory fitness in patients with heart failure and preserved ejection fraction. Minerva Cardiol Angiol 2020; 69:438-445. [PMID: 32996304 DOI: 10.23736/s2724-5683.20.05295-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Left ventricular (LV) concentric remodeling refers to a process by which increased LV relative wall thickness alters myocardial geometry, resulting in reduced LV end-diastolic volume (LVEDV) and stroke volume (SV). While the degree of concentric remodeling is a negative prognostic factor in heart failure with preserved ejection fraction (HFpEF), it is not known how it contributes to cardiorespiratory fitness (CRF). METHODS We performed a retrospective analysis of patients with HFpEF who underwent treadmill single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) and cardiopulmonary exercise testing (CPX). From exercise SPECT-MPI, we recorded postexercise LVEDVi, LVESVi, SVi, LVEF, the presence and extent of perfusion defects, and perfusion reversibility. Peak oxygen consumption (VO<inf>2</inf>), the oxygen uptake efficiency slope (OUES), oxygen (O<inf>2</inf>) pulse, ventilatory efficiency (V<inf>E</inf>/VCO<inf>2</inf> slope), ventilatory anaerobic threshold, respiratory exchange ratio, exercise time, and maximum heart rate were obtained from CPX. Data are expressed as mean (±standard deviation). Univariate and multivariate linear regression was performed. RESULTS We identified 23 subjects who had completed both an exercise SPECT-MPI and a CPX. Patients were more commonly women (83%), black (65%), middle age (50 [±7.3] years), and obese (Body Mass Index [BMI] 39.7 [±6.0] kg/m2). Greater LVEDVi and LVESVi correlated positively with peak VO<inf>2</inf> (R=+0.648, P=0.001; R=+0.601, P=0.002), O<inf>2</inf> pulse (R=+0.686, P<0.001; R=+0.625, P=0.001) and OUES (R=+0.882, P<0.001; R=+0.779, P<0.001). The LVEF correlated inversely with peak VO<inf>2</inf> and OUES (R=-0.450, P=0.031; R=-0.485, P=0.035). Perfusion defect area, grade of severity, and presence of reversibility were not associated with CRF variables. CONCLUSIONS Postexercise reduced LV volumes correlate with measures of impaired CRF in patients with HFpEF, thus supporting a pathophysiologic role of concentric remodeling in impaired CRF in HFpEF.
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Affiliation(s)
- Justin Heizer
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Salvatore Carbone
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA.,Department of Kinesiology and Health Sciences, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Hayley E Billingsley
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA.,Department of Kinesiology and Health Sciences, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Benjamin W VAN Tassell
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Ross Arena
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Antonio Abbate
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Justin M Canada
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA -
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55
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Peverill RE. Understanding preload and preload reserve within the conceptual framework of a limited range of possible left ventricular end-diastolic volumes. ADVANCES IN PHYSIOLOGY EDUCATION 2020; 44:414-422. [PMID: 32697153 DOI: 10.1152/advan.00043.2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Preload has been variously defined, but if there is to be a direct relationship with activity of the Frank-Starling mechanism in its action to increase the force and extent of contraction, preload must directly reflect myocardial stretch. The Frank-Starling mechanism is activated during any stretch of a cardiac chamber beyond its resting size, which is present immediately before contraction. Every left ventricle has an intrinsic and limited range of possible volumes at end diastole. There is a curvilinear relationship between left ventricular (LV) end-diastolic pressure (LVEDP) and LV end-diastolic volume (LVEDV), and, at maximal or near maximal LVEDV, there will be a high LVEDP. Within the possible range, the LVEDV will be determined by the extent of filling, any change in LVEDV will result in changed activity of the Frank-Starling mechanism, and change in LVEDV might, therefore, be considered to represent change in preload. On the other hand, it is the difference between the current and the maximal possible LVEDV (or the preload reserve) that may be of the most clinical relevance. There is a reciprocal relationship between preload and preload reserve, with minor or absent LV preload reserve indicating that there will be either minimal or no increase in stroke volume following intravenous fluid administration. As left atrial pressure can remain within the normal range when the LVEDP is elevated, it is LVEDP, and not left atrial pressure, that provides the most reliable guide to preload reserve in an individual at a specific period in time.
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Affiliation(s)
- Roger E Peverill
- Monash Cardiovascular Research Centre, MonashHeart, Monash Health, Clayton, Victoria, Australia
- Department of Medicine, School of Clinical Sciences at Monash Medical Centre, Monash University, Clayton, Victoria, Australia
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56
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Haraldsdottir K, Watson AM, Pegelow DF, Palta M, Tetri LH, Levin T, Brix MD, Centanni RM, Goss KN, Eldridge MM. Blunted cardiac output response to exercise in adolescents born preterm. Eur J Appl Physiol 2020; 120:2547-2554. [DOI: 10.1007/s00421-020-04480-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/19/2020] [Indexed: 12/17/2022]
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57
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Mizobuchi A, Osawa K, Tanaka M, Yumoto A, Saito H, Fuke S. Detrended fluctuation analysis can detect the impairment of heart rate regulation in patients with heart failure with preserved ejection fraction. J Cardiol 2020; 77:72-78. [PMID: 32826140 DOI: 10.1016/j.jjcc.2020.07.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/05/2020] [Accepted: 07/08/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The impairment of short-term heart rate regulation in patients with heart failure with preserved ejection fraction (HFpEF) can cause acute hemodynamic collapse. Detrended fluctuation analysis (DFA) is a useful tool for the diagnosis of heart diseases and the prediction of mortality. In DFA, the short-term scaling exponent α is decreased in heart failure. However, its change in HFpEF patients remains unclear. METHODS Twenty patients diagnosed with HFpEF [defined as brain natriuretic peptide (BNP) >100 pg/mL, ejection fraction (EF) ≥50%, and without significant valvular disease], 20 diagnosed with non-HFpEF (BNP > 100 pg/mL and EF < 50%), and 20 control subjects generally matched for age and gender were enrolled. Holter electrocardiography was performed, and heart rate variability was calculated. In the DFA, the scaling exponents in 1000 beats were calculated for each 15-min segment and the average of all segments was used. We compared both the short-term (<11 beats, α1) and long-term (≥11 beats, α2) scaling exponents among the three groups. RESULTS In the HFpEF, non-HFpEF, and control groups, α1 was 0.73 ± 0.27, 0.66 ± 0.29, and 1.01 ± 0.20 (p < 0.01), and α2 was 0.95 ± 0.08, 0.88 ± 0.11, and 0.96 ± 0.07 (p < 0.01), respectively. The α1 exponent was significantly decreased in the HFpEF group (p < 0.01 vs. control) and the non-HFpEF group (p < 0.01 vs. control), while the α2 exponent was significantly decreased in the non-HFpEF group only (p < 0.05 vs. HFpEF and control). CONCLUSIONS Short-term heart rate regulation is impaired in patients with HFpEF, while patients with non-HFpEF have both short-term and long-term impairment.
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Affiliation(s)
- Asako Mizobuchi
- Department of Cardiovascular Medicine, Japanese Red Cross Okayama Hospital, Okayama, Japan.
| | - Kazuhiro Osawa
- Department of Cardiovascular Medicine, Japanese Red Cross Okayama Hospital, Okayama, Japan
| | - Masamichi Tanaka
- Department of Cardiovascular Medicine, Japanese Red Cross Okayama Hospital, Okayama, Japan
| | - Akihisa Yumoto
- Department of Cardiovascular Medicine, Japanese Red Cross Okayama Hospital, Okayama, Japan
| | - Hironori Saito
- Department of Cardiovascular Medicine, Japanese Red Cross Okayama Hospital, Okayama, Japan
| | - Soichiro Fuke
- Department of Cardiovascular Medicine, Japanese Red Cross Okayama Hospital, Okayama, Japan
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58
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Parasuraman SK, Loudon BL, Lowery C, Cameron D, Singh S, Schwarz K, Gollop ND, Rudd A, McKiddie F, Phillips JJ, Prasad SK, Wilson AM, Sen-Chowdhry S, Clark A, Vassiliou VS, Dawson DK, Frenneaux MP. Diastolic Ventricular Interaction in Heart Failure With Preserved Ejection Fraction. J Am Heart Assoc 2020; 8:e010114. [PMID: 30922153 PMCID: PMC6509705 DOI: 10.1161/jaha.118.010114] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background Exercise‐induced pulmonary hypertension is common in heart failure with preserved ejection fraction (HFpEF). We hypothesized that this could result in pericardial constraint and diastolic ventricular interaction in some patients during exercise. Methods and Results Contrast stress echocardiography was performed in 30 HFpEF patients, 17 hypertensive controls, and 17 normotensive controls (healthy). Cardiac volumes, and normalized radius of curvature (NRC) of the interventricular septum at end‐diastole and end‐systole, were measured at rest and peak‐exercise, and compared between the groups. The septum was circular at rest in all 3 groups at end‐diastole. At peak‐exercise, end‐systolic NRC increased to 1.47±0.05 (P<0.001) in HFpEF patients, confirming development of pulmonary hypertension. End‐diastolic NRC also increased to 1.54±0.07 (P<0.001) in HFpEF patients, indicating septal flattening, and this correlated significantly with end‐systolic NRC (ρ=0.51, P=0.007). In hypertensive controls and healthy controls, peak‐exercise end‐systolic NRC increased, but this was significantly less than observed in HFpEF patients (HFpEF, P=0.02 versus hypertensive controls; P<0.001 versus healthy). There were also small, non‐significant increases in end‐diastolic NRC in both groups (hypertensive controls, +0.17±0.05, P=0.38; healthy, +0.06±0.03, P=0.93). In HFpEF patients, peak‐exercise end‐diastolic NRC also negatively correlated (r=−0.40, P<0.05) with the change in left ventricular end‐diastolic volume with exercise (ie, the Frank‐Starling mechanism), and a trend was noted towards a negative correlation with change in stroke volume (r=−0.36, P=0.08). Conclusions Exercise pulmonary hypertension causes substantial diastolic ventricular interaction on exercise in some patients with HFpEF, and this restriction to left ventricular filling by the right ventricle exacerbates the pre‐existing impaired Frank‐Starling response in these patients.
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Affiliation(s)
| | - Brodie L Loudon
- 1 Norwich Medical School University of East Anglia Norwich United Kingdom
| | - Crystal Lowery
- 1 Norwich Medical School University of East Anglia Norwich United Kingdom
| | - Donnie Cameron
- 1 Norwich Medical School University of East Anglia Norwich United Kingdom
| | | | | | - Nicholas D Gollop
- 1 Norwich Medical School University of East Anglia Norwich United Kingdom
| | - Amelia Rudd
- 4 Department of Cardiology School of Medicine & Dentistry University of Aberdeen United Kingdom
| | - Fergus McKiddie
- 5 Nuclear Medicine Aberdeen Royal Infirmary NHS Grampian Aberdeen United Kingdom
| | - Jim J Phillips
- 5 Nuclear Medicine Aberdeen Royal Infirmary NHS Grampian Aberdeen United Kingdom
| | - Sanjay K Prasad
- 6 Royal Brompton Hospital and Imperial College London London United Kingdom
| | - Andrew M Wilson
- 1 Norwich Medical School University of East Anglia Norwich United Kingdom
| | - Srijita Sen-Chowdhry
- 7 Institute of Cardiovascular Science University College London London United Kingdom
| | - Allan Clark
- 1 Norwich Medical School University of East Anglia Norwich United Kingdom
| | | | - Dana K Dawson
- 4 Department of Cardiology School of Medicine & Dentistry University of Aberdeen United Kingdom
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59
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Pagel PS, Tawil JN, Boettcher BT, Izquierdo DA, Lazicki TJ, Crystal GJ, Freed JK. Heart Failure With Preserved Ejection Fraction: A Comprehensive Review and Update of Diagnosis, Pathophysiology, Treatment, and Perioperative Implications. J Cardiothorac Vasc Anesth 2020; 35:1839-1859. [PMID: 32747202 DOI: 10.1053/j.jvca.2020.07.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/15/2020] [Accepted: 07/02/2020] [Indexed: 02/07/2023]
Abstract
Almost three-quarters of all heart failure patients who are older than 65 have heart failure with preserved ejection fraction (HFpEF). The proportion and hospitalization rate of patients with HFpEF are increasing steadily relative to patients in whom heart failure occurs as result of reduced ejection fraction. The predominance of the HFpEF phenotype most likely is explained by the prevalence of medical conditions associated with an aging population. A multitude of age-related, medical, and lifestyle risk factors for HFpEF have been identified as potential causes for the sustained low-grade proinflammatory state that accelerates disease progression. Profound left ventricular (LV) systolic and diastolic stiffening, elevated LV filling pressures, reduced arterial compliance, left atrial hypertension, pulmonary venous congestion, and microvascular dysfunction characterize HFpEF, but pulmonary arterial hypertension, right ventricular dilation and dysfunction, and atrial fibrillation also frequently occur. These cardiovascular features make patients with HFpEF exquisitely sensitive to the development of hypotension in response to acute declines in LV preload or afterload that may occur during or after surgery. With the exception of symptom mitigation, lifestyle modifications, and rigorous control of comorbid conditions, few long-term treatment options exist for these unfortunate individuals. Patients with HFpEF present for surgery on a regular basis, and anesthesiologists need to be familiar with this heterogeneous and complex clinical syndrome to provide successful care. In this article, the authors review the diagnosis, pathophysiology, and treatment of HFpEF and also discuss its perioperative implications.
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Affiliation(s)
- Paul S Pagel
- Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI.
| | - Justin N Tawil
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Brent T Boettcher
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - David A Izquierdo
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Timothy J Lazicki
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - George J Crystal
- Department of Anesthesiology, University of Illinois College of Medicine, Chicago, IL
| | - Julie K Freed
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
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60
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Beyond the myocardium? SGLT2 inhibitors target peripheral components of reduced oxygen flux in the diabetic patient with heart failure with preserved ejection fraction. Heart Fail Rev 2020; 27:219-234. [PMID: 32583230 DOI: 10.1007/s10741-020-09996-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Recent cardiovascular outcome trials have highlighted the propensity of the antidiabetic agents, SGLT2 inhibitors (SGLT2is or -flozin drugs), to exert positive clinical outcomes in patients with cardiovascular disease at risk for major adverse cardiovascular events (MACEs). Of interest in cardiac diabetology is the physiological status of the patient with T2DM and heart failure with preserved ejection fraction (HFpEF), a well-examined association. Underlying this pathologic tandem are the effects that long-standing hyperglycemia has on the ability of the HFpEF heart to adequately deliver oxygen. It is believed that shortcomings in oxygen diffusion or utilization and the resulting hypoxia thereafter may play a role in underlying the clinical sequelae of patients with T2DM and HFpEF, with implications in the long-term decline of extra-cardiac tissue. Oxygen consumption is one of the most critical factors in indexing heart failure disease burden, warranting a probe into the role of SGLT2i on oxygen utility in HFpEF and T2DM. We investigated the role of oxygen flux in the patient with T2DM and HFpEF extending beyond the heart with focuses on cellular metabolism, perivascular fibrosis with endothelial dysfunction, hematologic changes, and renal effects with neurohormonal considerations in the patient with HFpEF and T2DM. Moreover, we give a commentary on potential therapeutic targets of these components with SGLT2i to gain insight into disease burden amelioration in patients with HFpEF and T2DM.
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61
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Kunimoto M, Shimada K, Yokoyama M, Matsubara T, Aikawa T, Ouchi S, Shimizu M, Fukao K, Miyazaki T, Kadoguchi T, Fujiwara K, Abulimiti A, Honzawa A, Yamada M, Shimada A, Yamamoto T, Asai T, Amano A, Smit AJ, Daida H. Association between the tissue accumulation of advanced glycation end products and exercise capacity in cardiac rehabilitation patients. BMC Cardiovasc Disord 2020; 20:195. [PMID: 32326893 PMCID: PMC7178950 DOI: 10.1186/s12872-020-01484-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 04/14/2020] [Indexed: 12/15/2022] Open
Abstract
Background Advanced glycation end products (AGEs) are associated with aging, diabetes mellitus (DM), and other chronic diseases. Recently, the accumulation of AGEs can be evaluated by skin autofluorescence (SAF). However, the relationship between SAF levels and exercise capacity in patients with cardiovascular disease (CVD) remains unclear. This study aimed to investigate the association between the tissue accumulation of AGEs and clinical characteristics, including exercise capacity, in patients with CVD. Methods We enrolled 319 consecutive CVD patients aged ≥40 years who underwent early phase II cardiac rehabilitation (CR) at our university hospital between November 2015 and September 2017. Patient background, clinical data, and the accumulation of AGEs assessed by SAF were recorded at the beginning of CR. Characteristics were compared between two patient groups divided according to the median SAF level (High SAF and Low SAF). Results The High SAF group was significantly older and exhibited a higher prevalence of DM than the Low SAF group. The sex ratio did not differ between the two groups. AGE levels showed significant negative correlations with peak oxygen uptake and ventilator efficiency (both P < 0.0001). Exercise capacity was significantly lower in the high SAF group than in the low SAF group, regardless of the presence or absence of DM (P < 0.05). A multivariate logistic regression analysis showed that SAF level was an independent factor associated with reduced exercise capacity (odds ratio 2.10; 95% confidence interval 1.13–4.05; P = 0.02). Conclusion High levels of tissue accumulated AGEs, as assessed by SAF, were significantly and independently associated with reduced exercise capacity. These data suggest that measuring the tissue accumulation of AGEs may be useful in patients who have undergone CR, irrespective of whether they have DM.
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Affiliation(s)
- Mitsuhiro Kunimoto
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Kazunori Shimada
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan. .,Cardiovascular Rehabilitation and Fitness, Juntendo University Hospital, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Miho Yokoyama
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.,Cardiovascular Rehabilitation and Fitness, Juntendo University Hospital, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Tomomi Matsubara
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Tatsuro Aikawa
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Shohei Ouchi
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Megumi Shimizu
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Kosuke Fukao
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Tetsuro Miyazaki
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Tomoyasu Kadoguchi
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Kei Fujiwara
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Abidan Abulimiti
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Akio Honzawa
- Cardiovascular Rehabilitation and Fitness, Juntendo University Hospital, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Miki Yamada
- Cardiovascular Rehabilitation and Fitness, Juntendo University Hospital, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Akie Shimada
- Department of Cardiovascular Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Taira Yamamoto
- Department of Cardiovascular Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Tohru Asai
- Department of Cardiovascular Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Atsushi Amano
- Department of Cardiovascular Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Andries J Smit
- Division of Vascular Medicine, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen, 9713 GZ, Netherlands
| | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.,Faculty of Health Science, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
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62
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Pandey A, Patel KV, Bahnson JL, Gaussoin SA, Martin CK, Balasubramanyam A, Johnson KC, McGuire DK, Bertoni AG, Kitzman D, Berry JD. Association of Intensive Lifestyle Intervention, Fitness, and Body Mass Index With Risk of Heart Failure in Overweight or Obese Adults With Type 2 Diabetes Mellitus: An Analysis From the Look AHEAD Trial. Circulation 2020; 141:1295-1306. [PMID: 32134326 PMCID: PMC9976290 DOI: 10.1161/circulationaha.119.044865] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Type 2 diabetes mellitus (T2DM) is associated with a higher risk for heart failure (HF). The impact of a lifestyle intervention and changes in cardiorespiratory fitness (CRF) and body mass index on risk for HF is not well established. METHODS Participants from the Look AHEAD trial (Action for Health in Diabetes) without prevalent HF were included. Time-to-event analyses were used to compare the risk of incident HF between the intensive lifestyle intervention and diabetes support and education groups. The associations of baseline measures of CRF estimated from a maximal treadmill test, body mass index, and longitudinal changes in these parameters with risk of HF were evaluated with multivariable adjusted Cox models. RESULTS Among the 5109 trial participants, there was no significant difference in the risk of incident HF (n=257) between the intensive lifestyle intervention and the diabetes support and education groups (hazard ratio, 0.96 [95% CI, 0.75-1.23]) over a median follow-up of 12.4 years. In the most adjusted Cox models, the risk of HF was 39% and 62% lower among moderate fit (tertile 2: hazard ratio, 0.61 [95% CI, 0.44-0.83]) and high fit (tertile 3: hazard ratio, 0.38 [95% CI, 0.24-0.59]) groups, respectively (referent group: low fit, tertile 1). Among HF subtypes, after adjustment for traditional cardiovascular risk factors and interval incidence of myocardial infarction, baseline CRF was not significantly associated with risk of incident HF with reduced ejection fraction. In contrast, the risk of incident HF with preserved ejection fraction was 40% lower in the moderate fit group and 77% lower in the high fit group. Baseline body mass index also was not associated with risk of incident HF, HF with preserved ejection fraction, or HF with reduced ejection fraction after adjustment for CRF and traditional cardiovascular risk factors. Among participants with repeat CRF assessments (n=3902), improvements in CRF and weight loss over a 4-year follow-up were significantly associated with lower risk of HF (hazard ratio per 10% increase in CRF, 0.90 [95% CI, 0.82-0.99]; per 10% decrease in body mass index, 0.80 [95% CI, 0.69-0.94]). CONCLUSIONS Among participants with type 2 diabetes mellitus in the Look AHEAD trial, the intensive lifestyle intervention did not appear to modify the risk of HF. Higher baseline CRF and sustained improvements in CRF and weight loss were associated with lower risk of HF. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00017953.
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Affiliation(s)
- Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Kershaw V. Patel
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Judy L. Bahnson
- Division of Public Health Sciences, Wake Forest University, Winston-Salem, NC
| | - Sarah A. Gaussoin
- Division of Public Health Sciences, Wake Forest University, Winston-Salem, NC
| | - Corby K. Martin
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA
| | - Ashok Balasubramanyam
- Section of Endocrinology, Diabetes, and Metabolism, Department of Internal Medicine, Baylor College of Medicine, Houston, TX
| | - Karen C. Johnson
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Darren K. McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Alain G. Bertoni
- Division of Public Health Sciences, Wake Forest University, Winston-Salem, NC
| | - Dalane Kitzman
- Department of Internal Medicine, Wake Forest University, Winston-Salem, NC
| | - Jarett D. Berry
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
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63
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Fukuta H, Goto T, Wakami K, Kamiya T, Ohte N. Effects of exercise training on cardiac function, exercise capacity, and quality of life in heart failure with preserved ejection fraction: a meta-analysis of randomized controlled trials. Heart Fail Rev 2020; 24:535-547. [PMID: 31032533 DOI: 10.1007/s10741-019-09774-5] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Left ventricular (LV) diastolic dysfunction is associated with the pathophysiology of heart failure with preserved ejection fraction (HFpEF) and contributes importantly to exercise intolerance that results in a reduced quality of life (QOL) in HFpEF patients. Although the effects of exercise training on LV diastolic function, exercise capacity, or QOL in HFpEF patients have been examined in randomized clinical trials (RCTs), results are inconsistent due partly to limited power with small sample sizes. We aimed to conduct a meta-analysis of RCTs examining the effects of exercise training on LV diastolic function and exercise capacity as well as QOL in HFpEF patients. The search of electronic databases identified 8 RCTs with 436 patients. The duration of exercise training ranged from 12 to 24 weeks. In the pooled analysis, exercise training improved peak exercise oxygen uptake (weighted mean difference [95% CI], 1.660 [0.973, 2.348] ml/min/kg), 6-min walk distance (33.883 [12.384 55.381] m), and Minnesota Living With Heart Failure Questionnaire total score (9.059 [3.083, 15.035] point) compared with control. In contrast, exercise training did not significantly change early diastolic mitral annular velocity (weighted mean difference [95% CI], 0.317 [- 0.952, 1.587] cm/s), the ratio of early diastolic mitral inflow to annular velocities (- 1.203 [- 4.065, 1.658]), or LV ejection fraction (0.850 [- 0.128, 1.828] %) compared with control. In conclusion, the present meta-analysis suggests that exercise training improves exercise capacity and QOL without significant change in LV systolic or diastolic function in HFpEF patients.
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Affiliation(s)
- Hidekatsu Fukuta
- Core Laboratory, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi Mizuho-cho Mizuho-ku, Nagoya, 467-8601, Japan.
| | - Toshihiko Goto
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Kazuaki Wakami
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takeshi Kamiya
- Department of Medical Innovation, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Nobuyuki Ohte
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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64
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Pieske B, Tschöpe C, de Boer RA, Fraser AG, Anker SD, Donal E, Edelmann F, Fu M, Guazzi M, Lam CSP, Lancellotti P, Melenovsky V, Morris DA, Nagel E, Pieske-Kraigher E, Ponikowski P, Solomon SD, Vasan RS, Rutten FH, Voors AA, Ruschitzka F, Paulus WJ, Seferovic P, Filippatos G. How to diagnose heart failure with preserved ejection fraction: the HFA-PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). Eur J Heart Fail 2020; 22:391-412. [PMID: 32133741 DOI: 10.1002/ejhf.1741] [Citation(s) in RCA: 180] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 10/30/2018] [Accepted: 08/26/2019] [Indexed: 12/11/2022] Open
Abstract
Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm'. Step 1 (P=Pre-test assessment) is typically performed in the ambulatory setting and includes assessment for heart failure symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non-cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular (LV) ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e'), LV filling pressure estimated using E/e', left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2-4 points) implies diagnostic uncertainty, in which case Step 3 (F1 : Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F2 : Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.
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Affiliation(s)
- Burkert Pieske
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum.,German Center for Cardiovascular Research (DZHK), Berlin, Partner Site, Germany.,Department of Internal Medicine and Cardiology, German Heart Institute, Berlin, Germany.,Berlin Institute of Health (BIH), Germany
| | - Carsten Tschöpe
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum.,German Center for Cardiovascular Research (DZHK), Berlin, Partner Site, Germany.,Berlin Institute of Health (BIH) Center for Regenerative Therapies (BCRT), Charite, Berlin, Germany
| | - Rudolf A de Boer
- University Medical Centre Groningen, University of Groningen, Department of Cardiology, Groningen, the Netherlands
| | | | - Stefan D Anker
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum.,German Center for Cardiovascular Research (DZHK), Berlin, Partner Site, Germany.,Berlin Institute of Health (BIH) Center for Regenerative Therapies (BCRT), Charite, Berlin, Germany.,Department of Cardiology and Pneumology, University Medicine Göttingen (UMG), Germany
| | - Erwan Donal
- Cardiology and CIC, IT1414, CHU de Rennes LTSI, Université Rennes-1, INSERM 1099, Rennes, France
| | - Frank Edelmann
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum.,German Center for Cardiovascular Research (DZHK), Berlin, Partner Site, Germany
| | - Michael Fu
- Section of Cardiology, Department of Medicine, Sahlgrenska University Hosptal/Ostra, Göteborg, Sweden
| | - Marco Guazzi
- Department of Biomedical Sciences for Health, University of Milan, IRCCS, Milan, Italy.,Department of Cardiology, IRCCS Policlinico, San Donato Milanese, Milan, Italy
| | - Carolyn S P Lam
- National Heart Centre, Singapore & Duke-National University of Singapore.,University Medical Centre Groningen, The Netherlands
| | - Patrizio Lancellotti
- Department of Cardiology, Heart Valve Clinic, University of Liège Hospital, GIGA Cardiovascular Sciences, CHU Sart Tilman, Liège, Belgium
| | - Vojtech Melenovsky
- Institute for Clinical and Experimental Medicine - IKEM, Prague, Czech Republic
| | - Daniel A Morris
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum
| | - Eike Nagel
- Institute for Experimental and Translational Cardiovascular Imaging, University Hospital Frankfurt.,German Centre for Cardiovascular Research (DZHK), Partner Site Frankfurt, Germany
| | - Elisabeth Pieske-Kraigher
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum
| | | | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ramachandran S Vasan
- Section of Preventive Medicine and Epidemiology and Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Adriaan A Voors
- University Medical Centre Groningen, University of Groningen, Department of Cardiology, Groningen, the Netherlands
| | - Frank Ruschitzka
- University Heart Centre, University Hospital Zurich, Switzerland
| | - Walter J Paulus
- Department of Physiology and Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, The Netherlands
| | - Petar Seferovic
- University of Belgrade School of Medicine, Belgrade University Medical Center, Serbia
| | - Gerasimos Filippatos
- Department of Cardiology, National and Kapodistrian University of Athens Medical School; University Hospital "Attikon", Athens, Greece.,University of Cyprus, School of Medicine, Nicosia, Cyprus
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65
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Arita T, Suzuki S, Kato Y, Kano H, Yajima J, Matsuno S, Otsuka T, Semba H, Uejima T, Oikawa Y, Nagashima K, Yagi N, Sagara K, Tanabe G, Yamashita T. Association between bisoprolol plasma concentration and worsening of heart failure: (CVI ARO 6). Drug Metab Pharmacokinet 2020; 35:228-237. [PMID: 32044255 DOI: 10.1016/j.dmpk.2020.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/04/2019] [Accepted: 01/06/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Although bisoprolol has been established to prevent heart failure (HF), finding the optimal dose remains a challenge. It is crucial to understand the distribution of bisoprolol plasma concentration (Bis-PC) and association with outcomes. METHODS This was a single-center observational study in 114 HF patients under once-daily bisoprolol. After obtaining trough Bis-PC, patients were followed-up for 1 year. The primary endpoint was worsening of HF. Patients were divided according to the tertiles of Bis-PC. RESULTS In multivariate logistic regression analysis, independent predictors of high Bis-PC (1st tertile: ≥ 5.38 ng/mL) were age, eGFR, and bisoprolol dose. The cumulative incidence rates of the primary endpoint were 10.5%/13.2%/26.3% in low/middle/high Bis-PC categories, respectively (log rank test, p = 0.087). Bis-PC was independently associated with the primary endpoint (hazard ratio [HR], 1.19 [per ng/mL], 95% CI 1.03-1.36). In subgroups, high Bis-PC was independently associated with the primary endpoint in elderly (HR 6.32, 95% CI 1.34-29.83) and HF with preserved ejection fraction (HFpEF) (HR 3.52, 95% CI 1.06-11.70). CONCLUSIONS Bis-PC was increased by age and renal dysfunction, and high Bis-PC was associated with worsening of HF in elderly and HFpEF patients. Care should be taken to avoid overdose.
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Affiliation(s)
- Takuto Arita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan.
| | - Shinya Suzuki
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Yuko Kato
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Hiroto Kano
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Junji Yajima
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Shunsuke Matsuno
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Takayuki Otsuka
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Hiroaki Semba
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Tokuhisa Uejima
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Yuji Oikawa
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Kazuyuki Nagashima
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Naoharu Yagi
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Koichi Sagara
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Gen Tanabe
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
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66
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Kumar AA, Kelly DP, Chirinos JA. Mitochondrial Dysfunction in Heart Failure With Preserved Ejection Fraction. Circulation 2019; 139:1435-1450. [PMID: 30856000 DOI: 10.1161/circulationaha.118.036259] [Citation(s) in RCA: 139] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a complex syndrome with an increasingly recognized heterogeneity in pathophysiology. Exercise intolerance is the hallmark of HFpEF and appears to be caused by both cardiac and peripheral abnormalities in the arterial tree and skeletal muscle. Mitochondrial abnormalities can significantly contribute to impaired oxygen utilization and the resulting exercise intolerance in HFpEF. We review key aspects of the complex biology of this organelle, the clinical relevance of mitochondrial function, the methods that are currently available to assess mitochondrial function in humans, and the evidence supporting a role for mitochondrial dysfunction in the pathophysiology of HFpEF. We also discuss the role of mitochondrial function as a therapeutic target, some key considerations for the design of early-phase clinical trials using agents that specifically target mitochondrial function to improve symptoms in patients with HFpEF, and ongoing trials with mitochondrial agents in HFpEF.
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Affiliation(s)
- Anupam A Kumar
- From the University of Pennsylvania Perelman School of Medicine, Philadelphia (A.K., D.P.K., J.C.)
| | - Daniel P Kelly
- From the University of Pennsylvania Perelman School of Medicine, Philadelphia (A.K., D.P.K., J.C.)
| | - Julio A Chirinos
- From the University of Pennsylvania Perelman School of Medicine, Philadelphia (A.K., D.P.K., J.C.).,the Hospital of the University of Pennsylvania, Philadelphia (J.C.)
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67
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Chen ZW, Huang CY, Cheng JF, Chen SY, Lin LY, Wu CK. Stress Echocardiography-Derived E/e' Predicts Abnormal Exercise Hemodynamics in Heart Failure With Preserved Ejection Fraction. Front Physiol 2019; 10:1470. [PMID: 31849715 PMCID: PMC6901703 DOI: 10.3389/fphys.2019.01470] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 11/14/2019] [Indexed: 12/18/2022] Open
Abstract
Background The correlation between echocardiographic parameters and hemodynamics data in patients with heart failure with preserved ejection fraction (HFpEF) is unclear. It is important to find a non-invasive echocardiographic parameter for predicting exercise pulmonary capillary wedge pressure (PCWP). Aim This study sought to determine the correlation between echocardiographic parameters and hemodynamics data at rest and during exercise in HFpEF patients. Methods and Results This study was a cross-sectional cohort exploratory analysis of baseline data from the ILO-HOPE trial. A total of 34 HFpEF patients were enrolled. The average age was 70 ± 12 years, and most (74%) were women. The patients underwent invasive cardiac catheterization and expired gas analysis at rest and during exercise. Echocardiography including tissue Doppler imaging was performed, and global longitudinal strain and other novel diastolic function indexes were analyzed at rest and during exercise. At rest, no significant correlation was noted between resting PCWP and echocardiographic parameters. However, a significant correlation was observed between post-exercise PCWP and stress E/e′ (septal, lateral, and mean) ratio (p = 0.003, 0.031, 0.012). Moreover, post-exercise ΔPCWP showed a good correlation with stress E/e′ (septal, lateral, and mean; all p ≤ 0.001) and global longitudinal strain (GLS) during exercise (p = 0.03). After multivariate regression analysis with adjustment for possible confounding factors including age and sex, there was still a significant correlation between post-exercise ΔPCWP and E/e′ (r = 0.62, p < 0.001 for E/e′mean). Conclusion Only stress echocardiography derived tissue Doppler E/e′ ratio is closely correlated with abnormal exercise hemodynamics (PCWP and post-exercise ΔPCWP) in HFpEF. This echocardiographic marker is substantially more sensitive than other novel echocardiographic parameters during exercise, and may have significant diagnostic utility for ambulatory HFpEF patients with dyspnea. Clinical Trial Registration https://www.clinicaltrials.gov, identifier NCT03620526.
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Affiliation(s)
- Zheng-Wei Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan.,Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Yun-Lin Branch, Yun-Lin, Taiwan
| | - Chen-Yu Huang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan.,Division of Cardiology, Department of Internal Medicine, Kinmen Hospital, Ministry of Health and Welfare, Kinmen, Taiwan
| | - Jen-Fang Cheng
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan.,Division of Cardiology, Department of Internal Medicine, Pingtung Hospital, Pingtung, Taiwan
| | - Ssu-Yuan Chen
- Department of Physical Medicine and Rehabilitation, Fu Jen Catholic University Hospital and Fu Jen Catholic University School of Medicine, New Taipei City, Taiwan.,Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Lian-Yu Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Cho-Kai Wu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan.,Cardiovascular Institute, Stanford University, Stanford, CA, United States
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68
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Barton GP, Vildberg L, Goss K, Aggarwal N, Eldridge M, McMillan AB. Simultaneous determination of dynamic cardiac metabolism and function using PET/MRI. J Nucl Cardiol 2019; 26:1946-1957. [PMID: 29717407 PMCID: PMC7851880 DOI: 10.1007/s12350-018-1287-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 04/13/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cardiac metabolic changes in heart disease precede overt contractile dysfunction. However, metabolism and function are not typically assessed together in clinical practice. The purpose of this study was to develop a cardiac positron emission tomography/magnetic resonance (PET/MR) stress test to assess the dynamic relationship between contractile function and metabolism in a preclinical model. METHODS Following an overnight fast, healthy pigs (45-50 kg) were anesthetized and mechanically ventilated. 18F-fluorodeoxyglucose (18F-FDG) solution was administered intravenously at a constant rate of 0.01 mL/s for 60 minutes. A cardiac PET/MR stress test was performed using normoxic gas (FIO2 = .209) and hypoxic gas (FIO2 = .12). Simultaneous cardiac imaging was performed on an integrated 3T PET/MR scanner. RESULTS Hypoxic stress induced a significant increase in heart rate, cardiac output, left ventricular (LV) ejection fraction (EF), and peak torsion. There was a significant decline in arterial SpO2, LV end-diastolic and end-systolic volumes in hypoxia. Increased LV systolic function was coupled with an increase in myocardial FDG uptake (Ki) during hypoxic stress. CONCLUSION PET/MR with continuous FDG infusion captures dynamic changes in both cardiac metabolism and contractile function. This technique warrants evaluation in human cardiac disease for assessment of subtle functional and metabolic abnormalities.
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Affiliation(s)
- Gregory P Barton
- Department of Pediatrics, UW School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave. H6/551 CSC, Madison, WI, 53792, USA.
- Rankin Laboratory of Pulmonary Medicine, University of Wisconsin-Madison, Madison, USA.
| | - Lauren Vildberg
- Department of Pediatrics, UW School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave. H6/551 CSC, Madison, WI, 53792, USA
- Rankin Laboratory of Pulmonary Medicine, University of Wisconsin-Madison, Madison, USA
| | - Kara Goss
- Department of Pediatrics, UW School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave. H6/551 CSC, Madison, WI, 53792, USA
- Department of Medicine, University of Wisconsin-Madison, Madison, USA
- Rankin Laboratory of Pulmonary Medicine, University of Wisconsin-Madison, Madison, USA
| | - Niti Aggarwal
- Division of Cardiovascular Disease Department of Medicine, University of Wisconsin-Madison, Madison, USA
- Department of Radiology, University of Wisconsin-Madison, Madison, USA
| | - Marlowe Eldridge
- Department of Pediatrics, UW School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave. H6/551 CSC, Madison, WI, 53792, USA
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, USA
- Rankin Laboratory of Pulmonary Medicine, University of Wisconsin-Madison, Madison, USA
| | - Alan B McMillan
- Department of Radiology, University of Wisconsin-Madison, Madison, USA
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69
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Cross TJ, Kim CH, Johnson BD, Lalande S. The interactions between respiratory and cardiovascular systems in systolic heart failure. J Appl Physiol (1985) 2019; 128:214-224. [PMID: 31774354 DOI: 10.1152/japplphysiol.00113.2019] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Heart failure (HF) is a complex and multifaceted disease. The disease affects multiple organ systems, including the respiratory system. This review provides three unique examples illustrating how the cardiovascular and respiratory systems interrelate because of the pathology of HF. Specifically, these examples outline the impact of HF pathophysiology on 1) respiratory mechanics and the mechanical "cost" of breathing; 2) mechanical interactions of the heart and lungs; and on 3) abnormalities of pulmonary gas exchange during exercise, and how this may be applied to treatment. The goal of this review is to, therefore, raise the awareness that HF, though primarily a disease of the heart, is accompanied by marked pathology of the respiratory system.
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Affiliation(s)
- Troy James Cross
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester Minnesota
| | - Chul-Ho Kim
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester Minnesota
| | - Bruce D Johnson
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester Minnesota
| | - Sophie Lalande
- Department of Kinesiology and Heath Education, University of Texas at Austin, Austin, Texas
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70
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Pandey A, Khera R, Park B, Haykowsky M, Borlaug BA, Lewis GD, Kitzman DW, Butler J, Berry JD. Relative Impairments in Hemodynamic Exercise Reserve Parameters in Heart Failure With Preserved Ejection Fraction: A Study-Level Pooled Analysis. JACC-HEART FAILURE 2019; 6:117-126. [PMID: 29413366 DOI: 10.1016/j.jchf.2017.10.014] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 10/21/2017] [Accepted: 10/23/2017] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The aim of this study was to compare the relative impairment in different exercise hemodynamic reserve parameters in patients with heart failure with preserved ejection fraction (HFpEF) and control patients using a study-level meta-analysis. BACKGROUND A cardinal manifestation of chronic HFpEF is severely decreased exercise capacity. Developing effective therapies for exercise intolerance in HFpEF requires optimal understanding of the factors underlying exercise intolerance. METHODS Data were included from 17 unique cohorts that measured peak oxygen uptake and hemodynamic or echocardiographic parameters during exercise in patients with HFpEF and control subjects in this meta-analysis. Standardized mean differences (SMDs) in the exercise reserve (exercise - resting) measures of hemodynamic or echocardiographic parameters between the HFpEF and control groups were pooled in a random-effects meta-analysis. RESULTS The pooled analysis included 910 patients with HFpEF and 476 control subjects. In pooled analysis, patients with HFpEF had significantly lower peak oxygen uptake (SMD: -2.13; 95% confidence interval [CI]: -2.68 to -1.57). Among hemodynamic exercise reserve parameters, the largest impairment was observed in chronotropic response reserve (change in heart rate from rest to peak exercise; SMD: -1.87; 95% CI: -2.44 to -1.29), followed by exaggerated increase in pulmonary capillary wedge pressure with exercise (SMD: 1.78; 95% CI: 1.46 to 2.09). Significant abnormalities were also observed in the arteriovenous oxygen difference reserve and stroke volume reserve between the HFpEF and control groups. CONCLUSIONS The most consistent and severe hemodynamic reserve abnormalities observed in patients with HFpEF were impairment in chronotropic reserve and exaggerated increase in pulmonary capillary wedge pressure with exercise. These may be important targets for therapeutic strategies to improve exercise tolerance in patients with HFpEF.
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Affiliation(s)
- Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwest Medical Center, Dallas, Texas
| | - Rohan Khera
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwest Medical Center, Dallas, Texas
| | - Bryan Park
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwest Medical Center, Dallas, Texas
| | - Mark Haykowsky
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, Texas
| | - Barry A Borlaug
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Gregory D Lewis
- Division of Cardiology, Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dalane W Kitzman
- Department of Internal Medicine, Sections on Cardiovascular Medicine and Geriatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Javed Butler
- Division of Cardiology, Department of Internal Medicine, Stony Brook University School of Medicine, New York, New York
| | - Jarett D Berry
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwest Medical Center, Dallas, Texas.
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Yamamoto J, Wakami K, Muto K, Kikuchi S, Goto T, Fukuta H, Seo Y, Ohte N. Verification of Echocardiographic Assessment of Left Ventricular Diastolic Dysfunction in Patients With Preserved Left Ventricular Ejection Fraction Using the American Society of Echocardiography and European Association of Cardiovascular Imaging 2016 Recommendations. Circ Rep 2019; 1:525-530. [PMID: 33693095 PMCID: PMC7897561 DOI: 10.1253/circrep.cr-19-0094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background:
Non-invasive evaluation of left ventricular (LV) diastolic dysfunction (DD) and elevated LV filling pressure are crucial for diagnosing heart failure. The 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging (ASE/EACVI) recommendations for evaluating elevated LV filling pressure (algorithm B) have acceptable diagnostic accuracy, including in patients with reduced LV ejection fraction (EF). No prior study, however, has assessed the diagnostic accuracy of algorithm A of the ASE/EACVI recommendations for evaluating LVDD in patients with normal LVEF. Methods and Results:
We evaluated the clinical relevance of algorithm A in 94 patients who underwent invasive LV pressure measurement. Algorithm A identified invasively defined LVDD (time constant τ≥48 ms and/or LV end-diastolic pressure ≥16 mmHg) with low sensitivity (22.4%) but high specificity (90.7%). Algorithm A also identified elevated LV filling pressure with low sensitivity (41.7%) but high specificity (87.5%), and with a high negative predictive value (90.9%). Conclusions:
Algorithm A may not be useful for screening LVDD in patients with normal LVEF. Negative findings using algorithm A, however, may identify a patient with normal LVDD with high specificity, and most of such patients will have LV pre-A pressure in the normal range.
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Affiliation(s)
- Junki Yamamoto
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences Nagoya Japan
| | - Kazuaki Wakami
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences Nagoya Japan
| | - Keisuke Muto
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences Nagoya Japan
| | - Shohei Kikuchi
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences Nagoya Japan
| | - Toshihiko Goto
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences Nagoya Japan
| | - Hidekatsu Fukuta
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences Nagoya Japan
| | - Yoshihiro Seo
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences Nagoya Japan
| | - Nobuyuki Ohte
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences Nagoya Japan
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AbouEzzeddine OF, Kemp BJ, Borlaug BA, Mullan BP, Behfar A, Pislaru SV, Fudim M, Redfield MM, Chareonthaitawee P. Myocardial Energetics in Heart Failure With Preserved Ejection Fraction. Circ Heart Fail 2019; 12:e006240. [PMID: 31610726 DOI: 10.1161/circheartfailure.119.006240] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The role of coronary microvascular disease and its impact on functional and energetic reserve in heart failure with preserved ejection fraction (HFpEF) remains unclear. We hypothesized that in response to submaximal pharmacologic stress (dobutamine), patients with HFpEF have impairment in left ventricular (LV) myocardial mechanical (external work [EW]), energetic (myocardial O2 consumption [MVO2]), and myocardial blood flow (MBF) reserve. We further assessed whether coupling of MBF to EW is impaired in HFpEF and associated with compensatory increases or pathological decreases in myocardial O2 extraction. Lastly, we assessed whether coupling of MVO2 to EW (mechanical efficiency) was impaired in HFpEF. METHODS AND RESULTS In prospectively enrolled patients with HFpEF (n=19) and age/sex-matched healthy controls (n=19), we performed 11C-acetate positron emission tomography assessing MVO2 and MBF at rest and during dobutamine infusion. EW was calculated as stroke volume (echo)×end-systolic pressure×heart rate. At rest, compared with controls, patients with HFpEF had higher LV EW, MVO2, and MBF. With dobutamine, LV EW, MVO2, and MBF increased in both HFpEF and controls; however, the magnitude of increases was significantly smaller in HFpEF. In both groups, MBF increased in relation to EW, but in HFpEF, the slope of the relationship was significantly smaller than in controls. Myocardial O2 extraction was increased in HFpEF. Mechanical efficiency was similar in HFpEF and controls. In a post hoc analysis, HFpEF patients with LV hypertrophy (n=10) had significant reductions in LV mechanical efficiency relative to controls. CONCLUSIONS In HFpEF during submaximal dobutamine stress, there is myocardial mechanical-, energetic- and flow-reserve dysfunction with impaired coupling of blood flow to demand and slight increases in myocardial O2 extraction. These findings provide evidence that coronary microvascular dysfunction is present in HFpEF, limits O2 supply relative to demand, and is associated with reserve dysfunction.
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Affiliation(s)
- Omar F AbouEzzeddine
- Department of Cardiovascular Medicine (O.F.A., B.A.B., A.B., S.V.P., M.M.R., P.C.), Mayo Clinic, Rochester, MN
| | - Bradley J Kemp
- Department of Radiology (B.J.K., B.P.M.), Mayo Clinic, Rochester, MN
| | - Barry A Borlaug
- Department of Cardiovascular Medicine (O.F.A., B.A.B., A.B., S.V.P., M.M.R., P.C.), Mayo Clinic, Rochester, MN
| | - Brian P Mullan
- Department of Radiology (B.J.K., B.P.M.), Mayo Clinic, Rochester, MN
| | - Atta Behfar
- Department of Cardiovascular Medicine (O.F.A., B.A.B., A.B., S.V.P., M.M.R., P.C.), Mayo Clinic, Rochester, MN
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine (O.F.A., B.A.B., A.B., S.V.P., M.M.R., P.C.), Mayo Clinic, Rochester, MN
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, NC (M.F.)
| | - Margaret M Redfield
- Department of Cardiovascular Medicine (O.F.A., B.A.B., A.B., S.V.P., M.M.R., P.C.), Mayo Clinic, Rochester, MN
| | - Panithaya Chareonthaitawee
- Department of Cardiovascular Medicine (O.F.A., B.A.B., A.B., S.V.P., M.M.R., P.C.), Mayo Clinic, Rochester, MN
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Tucker WJ, Haykowsky MJ, Seo Y, Stehling E, Forman DE. Impaired Exercise Tolerance in Heart Failure: Role of Skeletal Muscle Morphology and Function. Curr Heart Fail Rep 2019; 15:323-331. [PMID: 30178183 DOI: 10.1007/s11897-018-0408-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW To discuss the impact of deleterious changes in skeletal muscle morphology and function on exercise intolerance in patients with heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF), as well as the utility of exercise training and the potential of novel treatment strategies to preserve or improve skeletal muscle morphology and function. RECENT FINDINGS Both HFrEF and HFpEF patients exhibit a reduction in percent of type I (oxidative) muscle fibers and oxidative enzymes coupled with abnormal mitochondrial respiration. These skeletal muscle abnormalities contribute to impaired oxidative metabolism with an earlier shift towards glycolytic metabolism during exercise that is strongly associated with exercise intolerance. In both HFrEF and HFpEF patients, peripheral "non-cardiac" factors are important determinants of the improvement in exercise tolerance following aerobic exercise training. Adjunctive strategies that include nutritional supplementation with amino acids and/or anabolic drugs to stimulate anabolic molecular pathways in skeletal muscle show great promise for improving exercise tolerance and treating heart failure-associated sarcopenia, but these efforts remain early in their evolution, with no immediate clinical applications. There is consistent evidence that heart failure is associated with multiple skeletal muscle abnormalities which impair oxygen uptake and utilization and contribute greatly to exercise intolerance. Exercise training induces favorable adaptations in skeletal muscle morphology and function that contribute to improvements in exercise tolerance in patients with HFrEF. The contribution of skeletal muscle adaptations to improved exercise tolerance following exercise training in HFpEF remains unknown and warrants further investigation.
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Affiliation(s)
| | | | - Yaewon Seo
- The University of Texas at Arlington, Arlington, TX, USA
| | - Elisa Stehling
- The University of Texas at Arlington, Arlington, TX, USA
| | - Daniel E Forman
- Department of Medicine, Section of Geriatric Cardiology, Veterans Affairs Geriatric Research Education, and Clinical Center, University of Pittsburgh, 3471 Fifth Avenue, Suite 500, Pittsburgh, PA, 15213, USA.
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74
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Jordan JH, Castellino SM, Meléndez GC, Klepin HD, Ellis LR, Lamar Z, Vasu S, Kitzman DW, Ntim WO, Brubaker PH, Reichek N, D'Agostino RB, Hundley WG. Left Ventricular Mass Change After Anthracycline Chemotherapy. Circ Heart Fail 2019; 11:e004560. [PMID: 29991488 DOI: 10.1161/circheartfailure.117.004560] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 05/04/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Myocardial atrophy and left ventricular (LV) mass reductions are associated with fatigue and exercise intolerance. The relationships between the receipt of anthracycline-based chemotherapy (Anth-bC) and changes in LV mass and heart failure (HF) symptomatology are unknown, as is their relationship to LV ejection fraction (LVEF), a widely used measurement performed in surveillance strategies designed to avert symptomatic HF associated with cancer treatment. METHODS AND RESULTS We performed blinded, serial assessments of body weight, LVEF and mass, LV-arterial coupling, aortic stiffness, and Minnesota Living with Heart Failure Questionnaire measures before and 6 months after initiating Anth-bC (n=61) and non-Anth-bC (n=15), and in 24 cancer-free controls using paired t and χ2 tests and multivariable linear models. Participants averaged 51±12 years, and 70% were women. Cancer diagnoses included breast cancer (53%), hematologic malignancy (42%), and soft tissue sarcoma (5%). We observed a 5% decline in both LVEF (P<0.0001) and LV mass (P=0.03) in the setting of increased aortic stiffness and disrupted ventricular-arterial coupling in those receiving Anth-bC but not other groups (P=0.11-0.92). A worsening of the Minnesota Living with Heart Failure Questionnaire score in Anth-bC recipients was associated with myocardial mass declines (r=-0.27; P<0.01) but not with LVEF declines (r=0.11; P=0.45). Moreover, this finding was independent of LVEF changes and body weight. CONCLUSIONS Early after Anth-bC, LV mass reductions associate with worsening HF symptomatology independent of LVEF. These data suggest an alternative mechanism whereby anthracyclines may contribute to HF symptomatology and raise the possibility that surveillance strategies during Anth-bC should also assess LV mass.
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Affiliation(s)
- Jennifer H Jordan
- Sections on Cardiovascular Medicine (J.H.J., G.C.M., S.V., D.W.K., W.O.N., W.G.H.)
| | | | - Giselle C Meléndez
- Sections on Cardiovascular Medicine (J.H.J., G.C.M., S.V., D.W.K., W.O.N., W.G.H.).,Department of Internal Medicine, Section on Comparative Medicine, Department of Pathology (G.C.M.)
| | | | | | | | - Sujethra Vasu
- Sections on Cardiovascular Medicine (J.H.J., G.C.M., S.V., D.W.K., W.O.N., W.G.H.)
| | - Dalane W Kitzman
- Sections on Cardiovascular Medicine (J.H.J., G.C.M., S.V., D.W.K., W.O.N., W.G.H.)
| | - William O Ntim
- Sections on Cardiovascular Medicine (J.H.J., G.C.M., S.V., D.W.K., W.O.N., W.G.H.)
| | - Peter H Brubaker
- Wake Forest School of Medicine, and Department of Health and Exercise Sciences (P.H.B)
| | - Nathaniel Reichek
- Wake Forest University, Winston-Salem, NC. Research and Education, The Heart Center, St Francis Hospital, Roslyn, NY (N.R.)
| | - Ralph B D'Agostino
- Department of Biostatistical Sciences, Division of Public Health Sciences (R.B.D'A.)
| | - W Gregory Hundley
- Sections on Cardiovascular Medicine (J.H.J., G.C.M., S.V., D.W.K., W.O.N., W.G.H.) .,Department of Radiological Sciences (W.G.H.)
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75
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Hearon Jr CM, Sarma S, Dias KA, Hieda M, Levine BD. Impaired oxygen uptake kinetics in heart failure with preserved ejection fraction. Heart 2019; 105:1552-1558. [DOI: 10.1136/heartjnl-2019-314797] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 05/10/2019] [Accepted: 05/14/2019] [Indexed: 12/17/2022] Open
Abstract
ObjectiveThe time needed to increase oxygen utilisation to meet metabolic demand (V̇O2 kinetics) is impaired in heart failure (HF) with reduced ejection fraction and is an independent risk factor for HF mortality. It is not known if V̇O2 kinetics are slowed in HF with preserved ejection fraction (HFpEF). We tested the hypothesis that V̇O2 kinetics are slowed during submaximal exercise in HFpEF and that slower V̇O2 kinetics are related to impaired peripheral oxygen extraction.MethodsEighteen HFpEF patients (68±7 years, 10 women) and 18 healthy controls (69±6 years, 10 women) completed submaximal and peak exercise testing. Cardiac output (acetylene rebreathing, Q̇c), ventilatory oxygen uptake (V̇O2, Douglas bags) and arterial-venous O2 difference (a-vO2 difference) derived from Q̇c and V̇O2 were assessed during exercise. Breath-by-breath O2 uptake was measured continuously throughout submaximal exercise, and V̇O2 kinetics was quantified as mean response time (MRT).ResultsHFpEF patients had markedly slowed V̇O2 kinetics during submaximal exercise (MRT: control: 40.1±14.2, HFpEF: 65.4±27.7 s; p<0.002), despite no relative impairment in submaximal cardiac output (Q̇c: control: 8.6±1.7, HFpEF: 9.7±2.2 L/min; p=0.79). When stratified by MRT, HFpEF with an MRT ≥60 s demonstrated elevated Q̇c, and impaired peripheral oxygen extraction that was apparent during submaximal exercise compared with HFpEF with a MRT <60 s (submaximal a-vO2 difference: MRT <60 s: 9.7±2.1, MRT ≥60 s: 7.9±1.1 mL/100 mL; p=0.03).ConclusionHFpEF patients have slowed V̇O2 kinetics that are related to impaired peripheral oxygen utilisation. MRT can identify HFpEF patients with peripheral limitations to submaximal exercise capacity and may be a target for therapeutic intervention.
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76
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Montero D, Diaz-Canestro C. Skeletal Muscle O 2 Diffusion and the Limitation of Aerobic Capacity in Heart Failure: A Clarification. Front Cardiovasc Med 2019; 6:78. [PMID: 31245387 PMCID: PMC6581670 DOI: 10.3389/fcvm.2019.00078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 05/29/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- David Montero
- Faculty of Kinesiology, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Candela Diaz-Canestro
- Faculty of Kinesiology, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
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77
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Bytyci I, Bajraktari G, Fabiani I, Lindqvist P, Poniku A, Pugliese NR, Dini FL, Henein MY. Left atrial compliance index predicts exercise capacity in patients with heart failure and preserved ejection fraction irrespective of right ventricular dysfunction. Echocardiography 2019; 36:1045-1053. [PMID: 31148237 DOI: 10.1111/echo.14377] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 04/04/2019] [Accepted: 05/08/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND AIM Predictors of exercise capacity in heart failure (HF) with preserved ejection fraction (HFpEF) remain of difficult determination. The aim of this study was to identify predictors of exercise capacity in a group of patients with HFpEF and right ventricle (RV) dysfunction METHODS: In 143 consecutive patients with HFpEF (age 62 ± 9 years, LV EF ≥45) and 41 controls, a complete echocardiographic study was performed. In addition to conventional measurements, LA compliance was calculated using the formula: [LAV max - LAV min/LAV min × 100]. Exercise capacity was assessed using the six-minute walking test (6-MWT). Tricuspid annular plane systolic excursion (TAPSE) < 1.7 cm was utilized to categorize patients with RV dysfunction (n = 40) from those with maintained RV function (n = 103). RESULTS Patients with RV dysfunction were older (P = 0.002), had higher NYHA class (P = 0.001), higher LV mass index (P = 0.01), reduced septal and lateral MAPSE (all P < 0.001), enlarged LA (P = 0.001) impaired LA compliance index (P < 0.001) and exhibited a more compromised 6-MWT (P = 0.001). LA compliance index correlated more closely with 6-MWT (r = 0.51, P < 0.001) compared with the other LA indices (AP diameter, transverse diameter and volume indexed; r = -0.30, r = -0.35 and r = -0.38, respectively). In multivariate analysis, LA compliance index <60% was 88% sensitive and 61% specific (AUC 0.80, CI = 0.67-0.92 P = 0.001) in predicting exercise capacity. CONCLUSION An impairment in LA compliance was profound in patients with HFpEF and RV dysfunction and seems to be most powerful independent predictor of limited exercise capacity.
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Affiliation(s)
- Ibadete Bytyci
- Institute of Public Health and Clinical Medicine, Umea University, Umea, Sweden
- Clinic of Cardiology, University Clinical Centre of Kosova, Prishtina, Kosovo
| | - Gani Bajraktari
- Institute of Public Health and Clinical Medicine, Umea University, Umea, Sweden
- Clinic of Cardiology, University Clinical Centre of Kosova, Prishtina, Kosovo
- Medical Faculty, University of Prishtina, Prishtina, Kosovo
| | - Iacopo Fabiani
- Cardiac, Thoracic and Vascular Department, University of Pisa, Pisa, Italy
| | - Per Lindqvist
- Institute of Public Health and Clinical Medicine, Umea University, Umea, Sweden
| | - Afrim Poniku
- Clinic of Cardiology, University Clinical Centre of Kosova, Prishtina, Kosovo
- St George University London, London, UK
| | | | - Frank L Dini
- Cardiac, Thoracic and Vascular Department, University of Pisa, Pisa, Italy
| | - Michael Y Henein
- Institute of Public Health and Clinical Medicine, Umea University, Umea, Sweden
- St George University London, London, UK
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78
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The Added Value of Exercise Stress Echocardiography in Patients With Heart Failure. Am J Cardiol 2019; 123:1470-1477. [PMID: 30777323 DOI: 10.1016/j.amjcard.2019.02.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 01/26/2019] [Accepted: 02/05/2019] [Indexed: 12/19/2022]
Abstract
Doppler echocardiography can provide reliable and repeatable measures of cardiac index (CI), whereas lung ultrasound (LUS) represents a quantitative approach to assess pulmonary congestion. We tested the hypothesis that simultaneous assessment of CI and LUS during exercise stress echocardiography (ESE) may define heart failure (HF) outpatients with different risk of adverse outcome. Standard transthoracic echocardiography and LUS (B-lines) evaluation were assessed during semisupine ESE. CI and B-lines were measured at baseline and peak exercise. Resting plasma B-type natriuretic peptide levels were also evaluated. We enrolled 105 HF patients (87 males; age 62 ± 11 years; New York Heart Association class I to III) with reduced left ventricular ejection fraction (30 ± 7%). Patients were classified into 4 profiles: (1) peak CI ≥4.0 l/min/m2 and peak B-lines <15 (no evidence of congestion or hypoperfusion, n = 47); (2) peak CI ≥4.0 l/min/m2 and peak B-lines ≥15 (congestion with adequate perfusion, n = 23); (3) peak CI <4.0 l/min/m2 and peak B-lines <15 (hypoperfusion without congestion, n = 13); and (4) peak CI <4.0 l/min/m2 and peak B-lines ≥15 (congestion and hypoperfusion, n = 22). There were 21 cardiovascular deaths and 18 hospitalizations for worsening HF during a median follow-up of 29 months. Multivariate predictors of the combined end point were peak hemodynamic profiles (hazard ratio [HR] 1.62, 95% confidence interval [CI] 1.19 to 2.21; p = 0.002), B-type natriuretic peptide (HR 1.00, 95% CI 1.00 to 1.01; p = 0.001), and rest E/e' (HR 1.09, 95% CI 1.03 to 1.15; p = 0.002). Survival analysis showed a worse survival in patients with ESE-derived D profile, followed by patients with C, B, and A profile (log-rank: chi-square = 40.5; p <0.0001). In conclusion, dual evaluation of CI and LUS during ESE is useful for risk stratification of HF patients with reduced ejection fraction. Evidence of pulmonary congestion and low CI at peak ESE identifies a subgroup with a very high risk of adverse outcome.
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79
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Borlaug BA. Can Oxygen Transport Analysis Tell Us Why People With Heart Failure With Preserved Ejection Fraction Feel So Poorly? Circulation 2019; 137:162-165. [PMID: 29311348 DOI: 10.1161/circulationaha.117.031528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
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80
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Wolsk E, Kaye D, Komtebedde J, Shah SJ, Borlaug BA, Burkhoff D, Kitzman DW, Lam CSP, van Veldhuisen DJ, Ponikowski P, Petrie MC, Hassager C, Møller JE, Gustafsson F. Central and Peripheral Determinants of Exercise Capacity in Heart Failure Patients With Preserved Ejection Fraction. JACC-HEART FAILURE 2019; 7:321-332. [PMID: 30852235 DOI: 10.1016/j.jchf.2019.01.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 12/30/2018] [Accepted: 01/04/2019] [Indexed: 01/10/2023]
Abstract
OBJECTIVES This study sought to discern which central (e.g., heart rate, stroke volume [SV], filling pressure) and peripheral factors (e.g., oxygen use by skeletal muscle, body mass index [BMI]) during exercise were most strongly associated with the presence of heart failure and preserved ejection fraction (HFpEF) as compared with healthy control subjects exercising at the same workload. BACKGROUND The underlying mechanisms limiting exercise capacity in patients with HFpEF are not fully understood. METHODS In patients with HFpEF (n = 108), the hemodynamic response at peak exercise was measured using right-sided heart catheterization and was compared with that in healthy control subjects (n = 42) at matched workloads to reveal hemodynamic differences that were not attributable to the workload performed. The patients studied were prospectively included in the REDUCE-LAP HF (Reduce Elevated Left Atrial Pressure in Patients With Heart Failure) trials and HemReX (Effect of Age on the Hemodynamic Response During Rest and Exercise in Healthy Humans) study. Univariable and multivariable logistic regression models were used to analyze variables associated with HFpEF versus control subjects. RESULTS Compared with healthy control subjects, pulmonary capillary wedge pressure (PCWP) and SV were the only independent hemodynamic variables that were associated with HFpEF, a finding explaining 66% (p < 0.0001) of the difference between the groups. When relevant baseline characteristics were added to the base model, only BMI emerged as an additional independent variable, in total explaining of 90% of the differences between groups (p < 0.0001): PCWP (47%), BMI (31%), and SV (12%). CONCLUSIONS The study identified 3 key variables (PCWP, BMI, and SV) that independently correlate with the presence of patients with HFpEF compared with healthy control subjects exercising at the same workload. Therapies that decrease left-sided heart filling pressures could improve exercise capacity and possibly prognosis.
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Affiliation(s)
- Emil Wolsk
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark.
| | - David Kaye
- Baker IDI Heart and Diabetes Research Institute, Melbourne, Australia
| | | | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Barry A Borlaug
- Division of Cardiovascular Diseases, Mayo Clinic and Foundation, Rochester, Minnesota
| | | | - Dalane W Kitzman
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Carolyn S P Lam
- National Heart Centre Singapore, Singapore, Singapore; Duke-National University of Singapore, Singapore; Department of Cardiology, University Medical Center Groningen, the Netherlands
| | - Dirk J van Veldhuisen
- National Heart Centre Singapore, Singapore, Singapore; Duke-National University of Singapore, Singapore
| | - Piotr Ponikowski
- Department of Heart Diseases, Medical University and Centre for Heart Diseases, Military Hospital, Wrocław, Poland
| | - Mark C Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | | | - Jacob E Møller
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
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81
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Orimoloye OA, Kambhampati S, Hicks AJ, Al Rifai M, Silverman MG, Whelton S, Qureshi W, Ehrman JK, Keteyian SJ, Brawner CA, Dardari Z, Al-Mallah MH, Blaha MJ. Higher cardiorespiratory fitness predicts long-term survival in patients with heart failure and preserved ejection fraction: the Henry Ford Exercise Testing (FIT) Project. Arch Med Sci 2019; 15:350-358. [PMID: 30899287 PMCID: PMC6425214 DOI: 10.5114/aoms.2019.83290] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 03/11/2018] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Higher cardiorespiratory fitness (CRF) is associated with improved exercise capacity and quality of life in heart failure with preserved ejection fraction (HFpEF), but there are no large studies evaluating the association of HFpEF, CRF, and long-term survival. We therefore aimed to determine the association between CRF and all-cause mortality, in patients with HFpEF. MATERIAL AND METHODS In the Henry Ford Exercise Testing (FIT) Project, 167 patients had baseline HFpEF, defined as a clinical diagnosis of heart failure with ejection fraction ≥ 50% on echocardiogram. The CRF was estimated from the peak workload (in METs) from a clinician-referred treadmill stress test and categorized as poor (1-4 METs), intermediate (5-6 METs), and moderate-high (≥ 7 METs). Additional analyses assessing the effect of HFpEF and CRF on mortality were also conducted, matching HFpEF patients to non-HFpEF patients using propensity scores. RESULTS Mean age was 64 ±13 years, with 55% women, and 46% Black. Over a median follow-up of 9.7 (5.2-18.9) years, there were 103 deaths. In fully adjusted models, moderate-high CRF was associated with 63% lower mortality risk (HR = 0.37, 95% CI: 0.18-0.73) compared to the poor-CRF group. In the propensity-matched cohort, HFpEF was associated with a HR of 2.3 (95% CI: 1.7-3.2) for mortality compared to non-HFpEF patients, which was attenuated to 1.8 (95% CI: 1.3-2.5) after adjusting for CRF. CONCLUSIONS Moderate-high CRF in patients with HFpEF is associated with improved survival, and differences in CRF partly explain the intrinsic risk of HFpEF. Randomized trials of interventions aimed at improving CRF in HFpEF are needed.
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Affiliation(s)
- Olusola A. Orimoloye
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Swetha Kambhampati
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Albert J. Hicks
- Department of Medicine/Cardiology Division, Baylor Scott & White Health, Temple, USA
| | - Mahmoud Al Rifai
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, USA
| | | | - Seamus Whelton
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Waqas Qureshi
- Division of Cardiovascular Medicine, Wake Forest University of Medicine, Winston Salem, NC, USA
| | - Jonathan K. Ehrman
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Steven J. Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Clinton A. Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Zeina Dardari
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Mouaz H. Al-Mallah
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Cardiac Center, Ministry of National Guard Health Affairs, Saudi Arabia
| | - Michael J. Blaha
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, USA
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82
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Esfandiari S, Wolsk E, Granton D, Azevedo L, Valle FH, Gustafsson F, Mak S. Pulmonary Arterial Wedge Pressure at Rest and During Exercise in Healthy Adults: A Systematic Review and Meta-analysis. J Card Fail 2019; 25:114-122. [DOI: 10.1016/j.cardfail.2018.10.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 09/28/2018] [Accepted: 10/16/2018] [Indexed: 12/28/2022]
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83
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Boyes NG, Eckstein J, Pylypchuk S, Marciniuk DD, Butcher SJ, Lahti DS, Dewa DMK, Haykowsky MJ, Wells CR, Tomczak CR. Effects of heavy-intensity priming exercise on pulmonary oxygen uptake kinetics and muscle oxygenation in heart failure with preserved ejection fraction. Am J Physiol Regul Integr Comp Physiol 2019; 316:R199-R209. [PMID: 30601707 DOI: 10.1152/ajpregu.00290.2018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Exercise intolerance is a hallmark feature in heart failure with preserved ejection fraction (HFpEF). Prior heavy exercise ("priming exercise") speeds pulmonary oxygen uptake (V̇o2p) kinetics in older adults through increased muscle oxygen delivery and/or alterations in mitochondrial metabolic activity. We tested the hypothesis that priming exercise would speed V̇o2p on-kinetics in patients with HFpEF because of acute improvements in muscle oxygen delivery. Seven patients with HFpEF performed three bouts of two exercise transitions: MOD1, rest to 4-min moderate-intensity cycling and MOD2, MOD1 preceded by heavy-intensity cycling. V̇o2p, heart rate (HR), total peripheral resistance (TPR), and vastus lateralis tissue oxygenation index (TOI; near-infrared spectroscopy) were measured, interpolated, time-aligned, and averaged. V̇o2p and HR were monoexponentially curve-fitted. TPR and TOI levels were analyzed as repeated measures between pretransition baseline, minimum value, and steady state. Significance was P < 0.05. Time constant (τ; tau) V̇o2p (MOD1 49 ± 16 s) was significantly faster after priming (41 ± 14 s; P = 0.002), and the effective HR τ was slower following priming (41 ± 27 vs. 51 ± 32 s; P = 0.025). TPR in both conditions decreased from baseline to minimum TPR ( P < 0.001), increased from minimum to steady state ( P = 0.041) but remained below baseline throughout ( P = 0.001). Priming increased baseline ( P = 0.003) and minimum TOI ( P = 0.002) and decreased the TOI muscle deoxygenation overshoot ( P = 0.041). Priming may speed the slow V̇o2p on-kinetics in HFpEF and increase muscle oxygen delivery (TOI) at the onset of and throughout exercise. Microvascular muscle oxygen delivery may limit exercise tolerance in HFpEF.
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Affiliation(s)
- Natasha G Boyes
- College of Kinesiology, University of Saskatchewan , Saskatoon, SK , Canada
| | - Janine Eckstein
- College of Medicine, University of Saskatchewan , Saskatoon, SK , Canada
| | - Stephen Pylypchuk
- College of Medicine, University of Saskatchewan , Saskatoon, SK , Canada
| | - Darcy D Marciniuk
- College of Medicine, University of Saskatchewan , Saskatoon, SK , Canada
| | - Scotty J Butcher
- School of Physical Therapy, University of Saskatchewan , Saskatoon, SK , Canada
| | - Dana S Lahti
- College of Kinesiology, University of Saskatchewan , Saskatoon, SK , Canada
| | - Dalisizwe M K Dewa
- College of Medicine, University of Saskatchewan , Saskatoon, SK , Canada
| | - Mark J Haykowsky
- Integrated Cardiovascular Exercise Physiology and Rehabilitation Laboratory, College of Nursing and Health Innovation, University of Texas at Arlington , Arlington, Texas
| | - Calvin R Wells
- College of Medicine, University of Saskatchewan , Saskatoon, SK , Canada
| | - Corey R Tomczak
- College of Kinesiology, University of Saskatchewan , Saskatoon, SK , Canada
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84
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Yamashita K, Kohjitani A, Miyata M, Ohno S, Tohya A, Ohishi M, Sugimura M. Predictive Factors of Postoperative Blood Pressure Abnormalities Following a Minor-to-Moderate Surgery. Int Heart J 2018; 59:1359-1367. [PMID: 30369572 DOI: 10.1536/ihj.17-612] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Myocardial ischemic events after non-cardiac surgery is still a serious problem, especially in older, high-risk patients. However, the prevalence and risk factors of blood pressure (BP) abnormalities, which may possibly lead to myocardial ischemic attack, have not been reported. Our aim is to elucidate predictive factors of postoperative BP abnormalities following a minor-to-moderate surgery, employing preoperative left ventricular diastolic function. Patients who underwent cardiac echocardiogram examination and received oral and maxillofacial surgery under general anesthesia were enrolled. The echocardiographic parameters of diastolic function were compared between patients who had postoperative BP abnormalities (hypertension-systolic blood pressure [SBP] ≥ 170 mmHg-or hypotension-SBP < 80 mmHg-episode) that required therapeutic interventions until 7 days after surgery and those who had no BP abnormalities. Of the 173 patients analyzed, 25 (14.4%) had BP abnormalities. BP abnormalities patients were older, having a larger proportion of diabetes mellitus, lower E/A ratio and e', and larger E/e' and left atrial dimension than those without BP abnormalities. Subanalyses revealed that the independent risk factors responsible for hypertension episodes (14 patients) were the mean e' (odd ratio [OR]: 0.434; 95% confidence interval [CI]: 0.229-0.824), diabetes mellitus (OR: 5.018; 95% CI: 1.030-24.436), SBP at hospitalization (OR: 1.099; 95% CI: 1.036-1.165), and operation time (hour; OR: 1.326; 95%CI: 1.109-1.586), while hypotension episodes (11 patients) were associated solely with operation time (OR: 1.206; 95% CI: 1.046-1.391). In conclusion, left ventricular diastolic dysfunction, increased insulin resistance, boosted SBP at hospitalization, and prolonged operation should be taken into consideration as risk factors of postoperative BP abnormalities, especially hypertension, following minor-to-moderate surgery.
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Affiliation(s)
- Kaoru Yamashita
- Department of Dental Anesthesiology, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Atsushi Kohjitani
- Department of Dental Anesthesiology, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Masaaki Miyata
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Sachi Ohno
- Department of Dental Anesthesiology, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Akina Tohya
- Department of Dental Anesthesiology, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Mitsuru Ohishi
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Mitsutaka Sugimura
- Department of Dental Anesthesiology, Graduate School of Medical and Dental Sciences, Kagoshima University
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85
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Shiba T, Takahashi M, Matsumoto T, Hori Y. Pulse Waveform Analysis in Ocular Microcirculation by Laser Speckle Flowgraphy in Patients with Left Ventricular Systolic and Diastolic Dysfunction. J Vasc Res 2018; 55:329-337. [DOI: 10.1159/000494066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 09/26/2018] [Indexed: 11/19/2022] Open
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86
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Novaes RD, Mouro VGS, Gonçalves RV, Mendonça AAS, Santos EC, Fialho MCQ, Machado-Neves M. Aluminum: A potentially toxic metal with dose-dependent effects on cardiac bioaccumulation, mineral distribution, DNA oxidation and microstructural remodeling. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2018; 242:814-826. [PMID: 30032078 DOI: 10.1016/j.envpol.2018.07.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/23/2018] [Accepted: 07/09/2018] [Indexed: 06/08/2023]
Abstract
Large amounts of aluminum (Al) are found in wastewater from industrial bauxite mining, which is often responsible for the contamination of drinking water sources in urban and rural communities. Although this metal exhibits broad environmental distribution, its cardiac repercussions are poorly understood, making it difficult to establish diagnostic criteria in cases of Al intoxication. In the absence of clinical data, we used a preclinical model to investigate the impact of Al exposure on heart bioaccumulation, molecular oxidation, micromineral distribution, structural and ultrastructural remodeling of the cardiac tissue. Male Wistar rats were equally randomized into five groups: G1 = distilled water; and G2 to G5 = 0.02, 0.1, 50, and 200 mg/kg aluminum solution, respectively. After 120 days, the hearts were collected and subjected to mineral microanalysis, immunoenzymatic detection of 8-OHdG, as well as bright field, polarizing, scanning and transmission electron microscopy to estimate the extent of the cardiac remodeling and cardiomyocytes ultrastructure. Long-term Al exposure induced dose-dependent bioaccumulation, micromineral imbalance, genomic DNA oxidation, structural and ultrastructural abnormalities of the cardiac tissue, resulting in extensive parenchymal loss, stromal expansion, diffuse inflammatory infiltrate, increased glycoconjugate and collagen deposition, subversion and collapse of the collagen network, reduced myocardial vascularization index, mitochondrial swelling, sarcomere disorganization, myofilament dissociation, and fragmentation in cardiomyocytes. Our findings indicated that the heart was sensitive to Al-mediated toxicity, especially in animals treated with the three highest doses of Al. In response to Al-induced loss of the parenchyma, heart stroma exhibited a reactive and compensatory expansion, which, in combination with the increased distribution of thick myofibrils and degenerated mitochondria in cardiomyocytes, provides morphological evidence that cardiac tissue adaptations are not enough to adjust the relationships between the parenchyma and stroma until a steady state is reached, resulting in continuous pathological remodeling potentially associated with Al-induced proinflammatory and pro-oxidant events.
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Affiliation(s)
- Rômulo D Novaes
- Institute of Biomedical Sciences, Department of Structural Biology, Federal University of Alfenas, MG, Brazil.
| | - Viviane G S Mouro
- Department of General Biology, Federal University of Viçosa, MG, Brazil
| | | | - Andrea A S Mendonça
- Institute of Biomedical Sciences, Department of Structural Biology, Federal University of Alfenas, MG, Brazil
| | - Eliziária C Santos
- Medicine School, Federal University of Jequitinhonha and Mucuri Valleys, MG, Brazil
| | - Maria C Q Fialho
- Department of Morphology, Federal University of Amazonas, AM, Brazil
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87
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Chronotropic Incompetence As Pathophysiological Mechanism Reduction of Exercise Tolerance in Patients with Arterial Hypertension and Clinical Signs of Heart Failure with Preserved Left Ventricular Ejection Fraction. Fam Med 2018. [DOI: 10.30841/2307-5112.4.2018.161253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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88
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Effects of mineralocorticoid receptor antagonists on left ventricular diastolic function, exercise capacity, and quality of life in heart failure with preserved ejection fraction: a meta-analysis of randomized controlled trials. Heart Vessels 2018; 34:597-606. [DOI: 10.1007/s00380-018-1279-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 10/05/2018] [Indexed: 10/28/2022]
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89
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Çetin S, Vural M, Akdemir R, Fırat H. Left atrial remodelling may predict exercise capacity in obstructive sleep apnoea patients. Acta Cardiol 2018; 73:471-478. [PMID: 29235925 DOI: 10.1080/00015385.2017.1414730] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Left atrial volume (LAV) and LA deformation has been proposed as a good marker of exercise performance in patients with diastolic dysfunction (DD). As DD is more prevalent in obstructive sleep apnoea (OSA) we aimed to evaluate the influence of LAV and LA deformation parameters on exercise performance in varying severity of OSA. MATERIALS AND METHODS OSA was diagnosed after polysomnography. Fifty-five OSA patients were enrolled in the study. OSA patients were divided into two groups with apnoea-hypopna-index (AHI) > 30 and <30. LAV was calculated. LA strain and LA strain rates were assessed with speckle tracking echocardiography (STE). Exercise capacity was evaluated by treadmill exercise test. RESULTS MET values were lower in group II compared to group I (p < .05). Echocardiographic findings: Comparison within groups: In both groups E/E', LA stain, LA strain rate S and LA strain rate E were higher after exercise than before (p < .05). In group I LA strain rate A was higher after exercise than before (p < .05). Comparison between groups: LA strain, LA strain rate S, LA strain rate E and LA strain rate A were lower and E/E' and LAVI were higher in group II compared to group I before and after exercise (p < .05). Correlation with METs: AHI, LVEDV, E/E' and LAVI were negatively and LA strain was positively correlated with METs (p < .05). CONCLUSIONS Left ventricular diastolic dysfunction is more prevalent in severe OSA and is associated with impaired exercise performance. Additionally, LA remodelling may predict exercise capacity in this subgroup of patients.
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Affiliation(s)
- Süha Çetin
- Department of Cardiology, Okan University Hospital , Istanbul , Turkey
| | - Mustafa Vural
- Department of Cardiology, Sakarya University School of Medicine , Sakarya , Turkey
| | - Ramazan Akdemir
- Department of Cardiology, Sakarya University School of Medicine , Sakarya , Turkey
| | - Hikmet Fırat
- Pulmonology Clinic, Ministery of Health Dışkapı Yıldırım Beyazıt Research and Educational Hospital , Ankara , Turkey
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90
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Mohananey D, Heidari-Bateni G, Villablanca PA, Iturrizaga Murrieta JC, Vlismas P, Agrawal S, Bhatia N, Mookadam F, Ramakrishna H. Heart Failure With Preserved Ejection Fraction—A Systematic Review and Analysis of Perioperative Outcomes. J Cardiothorac Vasc Anesth 2018; 32:2423-2434. [DOI: 10.1053/j.jvca.2017.11.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Indexed: 12/18/2022]
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91
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Bekfani T, Pellicori P, Morris D, Ebner N, Valentova M, Sandek A, Doehner W, Cleland JG, Lainscak M, Schulze PC, Anker SD, von Haehling S. Iron deficiency in patients with heart failure with preserved ejection fraction and its association with reduced exercise capacity, muscle strength and quality of life. Clin Res Cardiol 2018; 108:203-211. [PMID: 30051186 DOI: 10.1007/s00392-018-1344-x] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 07/19/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND The prevalence of iron deficiency (ID) in outpatients with heart failure with preserved ejection fraction (HFpEF) and its relation to exercise capacity and quality of life (QoL) is unknown. METHODS 190 symptomatic outpatients with HFpEF (LVEF 58 ± 7%; age 71 ± 9 years; NYHA 2.4 ± 0.5; BMI 31 ± 6 kg/m2) were enrolled as part of SICA-HF in Germany, England and Slovenia. ID was defined as ferritin < 100 or 100-299 µg/L with transferrin saturation (TSAT) < 20%. Anemia was defined as Hb < 13 g/dL in men, < 12 g/dL in women. Low ferritin-ID was defined as ferritin < 100 µg/L. Patients were divided into 3 groups according to E/e' at echocardiography: E/e' ≤ 8; E/e' 9-14; E/e' ≥ 15. All patients underwent echocardiography, cardiopulmonary exercise test (CPX), 6-min walk test (6-MWT), and QoL assessment using the EQ5D questionnaire. RESULTS Overall, 111 patients (58.4%) showed ID with 89 having low ferritin-ID (46.84%). 78 (41.1%) patients had isolated ID without anemia and 54 patients showed anemia (28.4%). ID was more prevalent in patients with more severe diastolic dysfunction: E/e' ≤ 8: 44.8% vs. E/e': 9-14: 53.2% vs. E/e' ≥ 15: 86.5% (p = 0.0004). Patients with ID performed worse during the 6MWT (420 ± 137 vs. 344 ± 124 m; p = 0.008) and had worse exercise time in CPX (645 ± 168 vs. 538 ± 178 s, p = 0.03). Patients with low ferritin-ID had lower QoL compared to those without ID (p = 0.03). CONCLUSION ID is a frequent co-morbidity in HFpEF and is associated with reduced exercise capacity and QoL. Its prevalence increases with increasing severity of diastolic dysfunction.
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Affiliation(s)
- Tarek Bekfani
- Department of Cardiology, Campus Virchow-Klinikum, Charité Medical School, Berlin, Germany.
- Division of Cardiology, Angiology, Pneumology and Intensive Medical Care, Department of Internal Medicine I, University Hospital Jena, Friedrich-Schiller-University, Jena, Germany.
| | | | - Daniel Morris
- Department of Cardiology, Campus Virchow-Klinikum, Charité Medical School, Berlin, Germany
| | - Nicole Ebner
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany
| | - Miroslava Valentova
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany
- Department of Internal Medicine, Comenius University, Bratislava, Slovakia
| | - Anja Sandek
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany
| | - Wolfram Doehner
- Department of Cardiology, Campus Virchow-Klinikum, Charité Medical School, Berlin, Germany
- Center for Stroke Research Berlin, Charité Medical School, Berlin, Germany
| | | | - Mitja Lainscak
- Department of Cardiology, Golnik University, Golnik, Slovenia
| | - P Christian Schulze
- Division of Cardiology, Angiology, Pneumology and Intensive Medical Care, Department of Internal Medicine I, University Hospital Jena, Friedrich-Schiller-University, Jena, Germany
| | - Stefan D Anker
- Division of Cardiology and Metabolism-Heart Failure, Cachexia and Sarcopenia, Department of Cardiology, Campus Virchow-Klinikum, Charité Medical School, Berlin, Germany
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité Medical School Berlin, Berlin, Germany
| | - Stephan von Haehling
- Department of Cardiology, Campus Virchow-Klinikum, Charité Medical School, Berlin, Germany
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany
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92
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Prasad SB, Holland DJ, Atherton JJ. Diastolic stress echocardiography: from basic principles to clinical applications. Heart 2018; 104:1739-1748. [PMID: 30030333 DOI: 10.1136/heartjnl-2017-312323] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 06/08/2018] [Accepted: 06/12/2018] [Indexed: 02/06/2023] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) looms as a major public heart challenge with increasing prevalence due to an ageing population. Diagnosis can be challenging due to non-specific symptomatology, low natriuretic peptide levels and equivocal diastology on resting echocardiography. Diastolic stress echocardiography represents a non-invasive option to refining the diagnosis in this subset of patients. Diastolic responses to exercise are most commonly measured with a non-invasive measure of left ventricular filling pressures (LVFP) estimated by the ratio of the early mitral inflow wave to early diastolic tissue velocity (E/e' ratio). This is measured pre- and post-exercise , and is highly feasible. An elevation of exercise E/e' >15 is classified as an abnormal response as per current guidelines. An alternative measure of exercise-related diastolic performance, the Diastolic Functional Reserve Index has also been proposed, but has not been as well studied as exercise E/e'. A number of studies have validated exercise E/e' as a measure of LVFP against invasively measured LVFP using simultaneous echocardiography-catheterisation studies. The independent prognostic value of exercise E/e' has also been well delineated in a number of studies. While diastolic stress echocardiography can be considered for all patients with suspected HFpEF, it is of particular value in patients with normal or equivocal diastolic indices on resting echocardiography.
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Affiliation(s)
- Sandhir B Prasad
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - David J Holland
- School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - John J Atherton
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
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93
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Montero D, Diaz-Cañestro C. Determinants of exercise intolerance in heart failure with preserved ejection fraction: A systematic review and meta-analysis. Int J Cardiol 2018; 254:224-229. [PMID: 29407095 DOI: 10.1016/j.ijcard.2017.10.114] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 10/08/2017] [Accepted: 10/31/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Severe exercise intolerance (EI), demonstrated by impaired peak oxygen consumption, intrinsically characterizes heart failure with preserved ejection fraction (HFpEF). Controversy exists on the determinants of EI in patients with HFpEF according to case-control studies. The purpose of this study is to systematically review and clarify the main (Fick) determinants of EI in HFpEF. METHODS We conducted a systematic search of MEDLINE, Scopus and Web of Science since their inceptions until January 2017 for articles assessing peak cardiac output and/or arteriovenous oxygen difference (a-vO2diffpeak) with incremental exercise in patients diagnosed with HFpEF and age-matched control individuals. Meta-analyses were performed to determine the standardized mean difference (SMD) in peak cardiac index (CIpeak) and a-vO2diffpeak between HFpEF and control groups. Subgroup and meta-regression analyses were used to evaluate potential moderating factors. RESULTS Ten studies were included after systematic review, comprising a total of 213 HFpEF patients and 179 age-matched control individuals (mean age=51-73years). After data pooling, CIpeak (n=392, SMD=-1.42; P<0.001) and a-vO2diffpeak (n=228, SMD=-0.52; P=0.002) were impaired in HFpEF patients. In subgroup analyses, a-vO2diffpeak was reduced in HFpEF versus healthy individuals (n=114, SMD=-0.85; P<0.001) but not compared with control patients without heart failure (n=92, SMD=-0.12; P=0.57). The SMD in a-vO2diffpeak was negatively associated with age (B=-0.05, P=0.046), difference in % females (B=-0.01, P=0.026) and prevalence of hypertension (B=-0.01, P=0.015) between HFpEF and control groups. CONCLUSIONS HFpEF is associated with a predominant impairment of CIpeak, accompanied by sex- and comorbidity-dependent reduced oxygen extraction at peak exercise.
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Affiliation(s)
- David Montero
- Department of Cardiology, University Hospital Zurich, Switzerland.
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94
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Howden EJ, Sarma S, Lawley JS, Opondo M, Cornwell W, Stoller D, Urey MA, Adams-Huet B, Levine BD. Reversing the Cardiac Effects of Sedentary Aging in Middle Age-A Randomized Controlled Trial: Implications For Heart Failure Prevention. Circulation 2018; 137:1549-1560. [PMID: 29311053 DOI: 10.1161/circulationaha.117.030617] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 11/07/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Poor fitness in middle age is a risk factor for heart failure, particularly heart failure with a preserved ejection fraction. The development of heart failure with a preserved ejection fraction is likely mediated through increased left ventricular (LV) stiffness, a consequence of sedentary aging. In a prospective, parallel group, randomized controlled trial, we examined the effect of 2 years of supervised high-intensity exercise training on LV stiffness. METHODS Sixty-one (48% male) healthy, sedentary, middle-aged participants (53±5 years) were randomly assigned to either 2 years of exercise training (n=34) or attention control (control; n=27). Right heart catheterization and 3-dimensional echocardiography were performed with preload manipulations to define LV end-diastolic pressure-volume relationships and Frank-Starling curves. LV stiffness was calculated by curve fit of the diastolic pressure-volume curve. Maximal oxygen uptake (Vo2max) was measured to quantify changes in fitness. RESULTS Fifty-three participants completed the study. Adherence to prescribed exercise sessions was 88±11%. Vo2max increased by 18% (exercise training: pre 29.0±4.8 to post 34.4±6.4; control: pre 29.5±5.3 to post 28.7±5.4, group×time P<0.001) and LV stiffness was reduced (right/downward shift in the end-diastolic pressure-volume relationships; preexercise training stiffness constant 0.072±0.037 to postexercise training 0.051±0.0268, P=0.0018), whereas there was no change in controls (group×time P<0.001; pre stiffness constant 0.0635±0.026 to post 0.062±0.031, P=0.83). Exercise increased LV end-diastolic volume (group×time P<0.001), whereas pulmonary capillary wedge pressure was unchanged, providing greater stroke volume for any given filling pressure (loading×group×time P=0.007). CONCLUSIONS In previously sedentary healthy middle-aged adults, 2 years of exercise training improved maximal oxygen uptake and decreased cardiac stiffness. Regular exercise training may provide protection against the future risk of heart failure with a preserved ejection fraction by preventing the increase in cardiac stiffness attributable to sedentary aging. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT02039154.
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Affiliation(s)
- Erin J Howden
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (E.J.H., S.S., J.S.L., M.O., W.C., D.S., M.A.U., B.D.L.).,University of Texas Southwestern Medical Center, Dallas (E.J.H., S.S., J.S.L., D.S., M.A.U., B.A.-H., B.D.L.).,The Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia (E.J.H.)
| | - Satyam Sarma
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (E.J.H., S.S., J.S.L., M.O., W.C., D.S., M.A.U., B.D.L.).,University of Texas Southwestern Medical Center, Dallas (E.J.H., S.S., J.S.L., D.S., M.A.U., B.A.-H., B.D.L.)
| | - Justin S Lawley
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (E.J.H., S.S., J.S.L., M.O., W.C., D.S., M.A.U., B.D.L.).,University of Texas Southwestern Medical Center, Dallas (E.J.H., S.S., J.S.L., D.S., M.A.U., B.A.-H., B.D.L.)
| | - Mildred Opondo
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (E.J.H., S.S., J.S.L., M.O., W.C., D.S., M.A.U., B.D.L.).,Stanford University, CA (M.O.)
| | - William Cornwell
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (E.J.H., S.S., J.S.L., M.O., W.C., D.S., M.A.U., B.D.L.).,University of Colorado Anschutz Medical Campus, Aurora (W.C.)
| | - Douglas Stoller
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (E.J.H., S.S., J.S.L., M.O., W.C., D.S., M.A.U., B.D.L.).,University of Texas Southwestern Medical Center, Dallas (E.J.H., S.S., J.S.L., D.S., M.A.U., B.A.-H., B.D.L.)
| | - Marcus A Urey
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (E.J.H., S.S., J.S.L., M.O., W.C., D.S., M.A.U., B.D.L.).,University of Texas Southwestern Medical Center, Dallas (E.J.H., S.S., J.S.L., D.S., M.A.U., B.A.-H., B.D.L.)
| | - Beverley Adams-Huet
- University of Texas Southwestern Medical Center, Dallas (E.J.H., S.S., J.S.L., D.S., M.A.U., B.A.-H., B.D.L.)
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (E.J.H., S.S., J.S.L., M.O., W.C., D.S., M.A.U., B.D.L.). .,University of Texas Southwestern Medical Center, Dallas (E.J.H., S.S., J.S.L., D.S., M.A.U., B.A.-H., B.D.L.)
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95
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Ha JW. Diastolic Stress Echocardiography to Quantify the Response of Diastolic Functional Indices to Dynamic Exercise in Abnormal Relaxation: Unmasking Diastolic Abnormalities is Getting Ready for Prime Time. Korean Circ J 2018; 48:755-759. [PMID: 30073815 PMCID: PMC6072660 DOI: 10.4070/kcj.2018.0164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 06/04/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jong-Won Ha
- Division of Cardiology, Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Korea
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96
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Iyngkaran P, Anavekar NS, Neil C, Thomas L, Hare DL. Shortness of breath in clinical practice: A case for left atrial function and exercise stress testing for a comprehensive diastolic heart failure workup. World J Methodol 2017; 7:117-128. [PMID: 29354484 PMCID: PMC5746665 DOI: 10.5662/wjm.v7.i4.117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 06/29/2017] [Accepted: 11/22/2017] [Indexed: 02/06/2023] Open
Abstract
The symptom cluster of shortness of breath (SOB) contributes significantly to the outpatient workload of cardiology services. The workup of these patients includes blood chemistry and biomarkers, imaging and functional testing of the heart and lungs. A diagnosis of diastolic heart failure is inferred through the exclusion of systolic abnormalities, a normal pulmonary function test and normal hemoglobin, coupled with diastolic abnormalities on echocardiography. Differentiating confounders such as obesity or deconditioning in a patient with diastolic abnormalities is difficult. While the most recent guidelines provide more avenues for diagnosis, such as incorporating the left atrial size, little emphasis is given to understanding left atrial function, which contributes to at least 25% of diastolic left ventricular filling; additionally, exercise stress testing to elicit symptoms and test the dynamics of diastolic parameters, especially when access to the "gold standard" invasive tests is lacking, presents clinical translational gaps. It is thus important in diastolic heart failure work up to understand left atrial mechanics and the role of exercise testing to build a comprehensive argument for the diagnosis of diastolic heart failure in a patient presenting with SOB.
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Affiliation(s)
- Pupalan Iyngkaran
- Department of Medicine, Northern Territory Medical School, Flinders University, Charles Darwin University Campus, Casuarina, NT 0815, Australia
| | - Nagesh S Anavekar
- Department of Cardiology, Northern Hospital, Northern Health, University of Melbourne, Melbourne, VIC 3076, Australia
| | - Christopher Neil
- Cardiology Unit Western Health, Department of Medicine, Western Precinct, University of Melbourne, Melbourne, VIC 3076, Australia
| | - Liza Thomas
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW 214, Australia
- Westmead Hospital, Westmead Clincal School, University of Sydney, NSW 2145, Australia
| | - David L Hare
- Cardiovascular Research, University of Melbourne, Melbourne, VIC 3076, Australia
- Heart Failure Services, Austin Health, Melbourne, VIC 3084, Australia
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97
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Rocco IS, Viceconte M, Pauletti HO, Matos-Garcia BC, Marcondi NO, Bublitz C, Bolzan DW, Moreira RSL, Reis MS, Hossne NA, Gomes WJ, Arena R, Guizilini S. Oxygen uptake on-kinetics during six-minute walk test predicts short-term outcomes after off-pump coronary artery bypass surgery. Disabil Rehabil 2017; 41:534-540. [PMID: 29279000 DOI: 10.1080/09638288.2017.1401673] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE We aimed to investigate the ability of oxygen uptake kinetics to predict short-term outcomes after off-pump coronary artery bypass grafting. METHODS Fifty-two patients aged 60.9 ± 7.8 years waiting for off-pump coronary artery bypass surgery were evaluated. The 6-min walk test distance was performed pre-operatively, while simultaneously using a portable cardiopulmonary testing device. The transition of oxygen uptake kinetics from rest to exercise was recorded to calculate oxygen uptake kinetics fitting a monoexponential regression model. Oxygen uptake at steady state, constant time, and mean response time corrected by work rate were analysed. Short-term clinical outcomes were evaluated during the early post-operative of off-pump coronary artery bypass surgery. RESULTS Multivariate analysis showed body mass index, surgery time, and mean response time corrected by work rate as independent predictors for short-term outcomes. The optimal mean response time corrected by work rate cut-off to estimate short-term clinical outcomes was 1.51 × 10-3 min2/ml. Patients with slower mean response time corrected by work rate demonstrated higher rates of hypertension, diabetes, EuroSCOREII, left ventricular dysfunction, and impaired 6-min walk test parameters. The per cent-predicted distance threshold of 66% in the pre-operative was associated with delayed oxygen uptake kinetics. CONCLUSIONS Pre-operative oxygen uptake kinetics during 6-min walk test predicts short-term clinical outcomes after off-pump coronary artery bypass surgery. From a clinically applicable perspective, a threshold of 66% of pre-operative predicted 6-min walk test distance indicated slower kinetics, which leads to longer intensive care unit and post-surgery hospital length of stay. Implications for rehabilitation Coronary artery bypass grafting is a treatment aimed to improve expectancy of life and prevent disability due to the disease progression; The use of pre-operative submaximal functional capacity test enabled the identification of patients with high risk of complications, where patients with delayed oxygen uptake kinetics exhibited worse short-term outcomes; Our findings suggest the importance of the rehabilitation in the pre-operative in order to "pre-habilitate" the patients to the surgical procedure; Faster oxygen uptake on-kinetics could be achieved by improving the oxidative capacity of muscles and cardiovascular conditioning through rehabilitation, adding better results following cardiac surgery.
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Affiliation(s)
- Isadora Salvador Rocco
- a Cardiology and Cardiovascular Surgery Disciplines , Federal University of Sao Paulo , Sao Paulo , Brazil.,b Department of Human Motion Sciences, Physical Therapy School , Federal University of Sao Paulo , Sao Paulo , Brazil
| | - Marcela Viceconte
- a Cardiology and Cardiovascular Surgery Disciplines , Federal University of Sao Paulo , Sao Paulo , Brazil.,b Department of Human Motion Sciences, Physical Therapy School , Federal University of Sao Paulo , Sao Paulo , Brazil
| | - Hayanne Osiro Pauletti
- a Cardiology and Cardiovascular Surgery Disciplines , Federal University of Sao Paulo , Sao Paulo , Brazil.,b Department of Human Motion Sciences, Physical Therapy School , Federal University of Sao Paulo , Sao Paulo , Brazil
| | - Bruna Caroline Matos-Garcia
- a Cardiology and Cardiovascular Surgery Disciplines , Federal University of Sao Paulo , Sao Paulo , Brazil.,b Department of Human Motion Sciences, Physical Therapy School , Federal University of Sao Paulo , Sao Paulo , Brazil
| | - Natasha Oliveira Marcondi
- a Cardiology and Cardiovascular Surgery Disciplines , Federal University of Sao Paulo , Sao Paulo , Brazil.,b Department of Human Motion Sciences, Physical Therapy School , Federal University of Sao Paulo , Sao Paulo , Brazil
| | - Caroline Bublitz
- a Cardiology and Cardiovascular Surgery Disciplines , Federal University of Sao Paulo , Sao Paulo , Brazil.,b Department of Human Motion Sciences, Physical Therapy School , Federal University of Sao Paulo , Sao Paulo , Brazil
| | - Douglas William Bolzan
- a Cardiology and Cardiovascular Surgery Disciplines , Federal University of Sao Paulo , Sao Paulo , Brazil
| | - Rita Simone Lopes Moreira
- a Cardiology and Cardiovascular Surgery Disciplines , Federal University of Sao Paulo , Sao Paulo , Brazil
| | - Michel Silva Reis
- c Department of Physical Therapy , Federal University of Rio de Janeiro , Rio de Janeiro , Brazil
| | - Nelson Américo Hossne
- a Cardiology and Cardiovascular Surgery Disciplines , Federal University of Sao Paulo , Sao Paulo , Brazil
| | - Walter José Gomes
- a Cardiology and Cardiovascular Surgery Disciplines , Federal University of Sao Paulo , Sao Paulo , Brazil
| | - Ross Arena
- d Department of Physical Therapy and Integrative Physiology Laboratory, College of Applied Health Sciences , University of Illinois at Chicago , Chicago , IL , USA
| | - Solange Guizilini
- a Cardiology and Cardiovascular Surgery Disciplines , Federal University of Sao Paulo , Sao Paulo , Brazil.,b Department of Human Motion Sciences, Physical Therapy School , Federal University of Sao Paulo , Sao Paulo , Brazil
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99
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Singh RM, Waqar T, Howarth FC, Adeghate E, Bidasee K, Singh J. Hyperglycemia-induced cardiac contractile dysfunction in the diabetic heart. Heart Fail Rev 2017; 23:37-54. [DOI: 10.1007/s10741-017-9663-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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100
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Roof SR, Ueyama Y, Mazhari R, Hamlin RL, Hartman JC, Ziolo MT, Reardon JE, Del Rio CL. CXL-1020, a Novel Nitroxyl (HNO) Prodrug, Is More Effective than Milrinone in Models of Diastolic Dysfunction-A Cardiovascular Therapeutic: An Efficacy and Safety Study in the Rat. Front Physiol 2017; 8:894. [PMID: 29209225 PMCID: PMC5701606 DOI: 10.3389/fphys.2017.00894] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 10/24/2017] [Indexed: 01/08/2023] Open
Abstract
The nitroxyl (HNO) prodrug, CXL-1020, induces vasorelaxation and improves cardiac function in canine models and patients with systolic heart failure (HF). HNO's unique mechanism of action may be applicable to a broader subset of cardiac patients. This study investigated the load-independent safety and efficacy of CXL-1020 in two rodent (rat) models of diastolic heart failure and explored potential drug interactions with common HF background therapies. In vivo left-ventricular hemodynamics/pressure-volume relationships assessed before/during a 30 min IV infusion of CXL-1020 demonstrated acute load-independent positive inotropic, lusitropic, and vasodilatory effects in normal rats. In rats with only diastolic dysfunction due to bilateral renal wrapping (RW) or pronounced diastolic and mild systolic dysfunction due to 4 weeks of chronic isoproterenol exposure (ISO), CXL-1020 attenuated the elevated LV filling pressures, improved the end diastolic pressure volume relationship, and accelerated relaxation. CXL-1020 facilitated Ca2+ re-uptake and enhanced myocyte relaxation in isolated cardiomyocytes from ISO rats. Compared to milrinone, CXL-1020 more effectively improved Ca2+ reuptake in ISO rats without concomitant chronotropy, and did not enhance Ca2+ entry via L-type Ca2+ channels nor increase myocardial arrhythmias/ectopic activity. Acute-therapy with CXL-1020 improved ventricular relaxation and Ca2+ cycling, in the setting of chronic induced diastolic dysfunction. CXL-1020's lusitropic effects were greater than those seen with the cAMP-dependent agent milrinone, and unlike milrinone it did not produce chronotropy or increased ectopy. HNO is a promising new potential therapy for both systolic and diastolic heart failure.
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Affiliation(s)
| | | | - Reza Mazhari
- Cardioxyl Pharmaceuticals, Chapel Hill, NC, United States
| | | | | | - Mark T Ziolo
- Ohio State University Columbus, Columbus, OH, United States
| | - John E Reardon
- Cardioxyl Pharmaceuticals, Chapel Hill, NC, United States
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